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Obama Renews Call For A 'Public Option' In Federal Health Law

NPR Health Blog - Mon, 07/11/2016 - 5:01pm

President Obama speaks in Dallas in 2013 about the technical problems that affected the initial rollout of the Affordable Care Act. Now, citing the law's success, he is urging Congress to expand the insurance offerings.

Brendan Smialowski/AFP/Getty Images

President Obama on Monday called on Congress to revisit the controversial idea of providing a government-run insurance plan as part of the offerings under the Affordable Care Act.

What's been described as the "public option" was jettisoned from the health law in 2009 by a handful of conservative Democrats in the Senate. Every Democrat's vote was needed to pass the bill in the face of unanimous Republican opposition.

But in a "special communication" article published Monday on the website of JAMA, the American Medical Association's top journal, the president says a lack of competition among insurance plan offerings in some regions may warrant a new look.

"Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited," Obama writes.

The president calls on Congress to take more steps to rein in the cost of prescription drugs and make government assistance more generous for those who still cannot afford health coverage; he also urges the 19 states that have not yet expanded the Medicaid program under the health law to do so.

The public option has been a point of controversy from the start. It was included in the version of the health law passed by the House of Representatives, and had support from most Democrats in the Senate, before it was dropped. Many liberals hoped — and conservatives feared — that having the government provide insurance alongside private companies would be a step toward a fully government-run system.

Presumptive Democratic presidential nominee Hillary Clinton — under pressure from Sen. Bernie Sanders' call for a single-payer government system — in February endorsed the idea of including a public option to allow people age 55 and older to purchase Medicare coverage.

On Saturday, as part of a deal with Sanders, Clinton announced she will also "pursue efforts to give Americans in every state in the country the choice of a public-option insurance plan," which is broader than what Obama is endorsing.

But even if Clinton wins and the Democrats take back control of Congress in November, a public option remains a political long shot.

Obama's article, titled "United States Health Care Reform: Progress to Date and Next Steps," is apparently the first by a sitting president to be published by the prestigious medical journal.

Along with these recommendations for further action, Obama's article includes a justification for the federal health law and statistics on how its implementation has improved insurance coverage for patients and improved health care quality.

Kristie Canegallo, the White House deputy chief of staff for implementation, says the article grew out of a comprehensive review of the law that the president requested from his staff late last year.

The review was to look at "what's working, what's not, and what we should do about it," Canegallo says. Upon receiving the review, she adds, Obama "thought it was important to share some of this publicly."

Among those parts of the law the administration says are working are the coverage provisions. "The number of uninsured individuals in the United States has declined from 49 million in 2010 to 29 million in 2015," the president writes.

The article also says that the health law has played a substantial role in slowing the rate of health spending.

"While the Great Recession and other factors played a role in recent trends, the [president's] Council of Economic Advisers has found evidence that the reforms introduced by the ACA helped both slow health care costs growth and drive improvements in the quality of care," says the article.

Jason Furman, chairman of the council, says the continuing slow growth in health spending so many years out from the recession makes the argument by some other economists that the turndown in the U.S. economy was mostly responsible for the slowing of health spending "absurd at this point."

While most of Obama's journal article is a chart-driven, footnoted recitation of the impact of the health law, he does use his perch to suggest that the current state of politics in Washington threatens progress going forward.

"Any change is difficult, but it is especially difficult in the face of hyperpartisanship," he writes. "Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported."

Republicans are continuing their assault on the health law. Just last week, two House committees released a joint investigative report and held two hearings asserting that the administration is illegally providing funds to help lower-income individuals pay for their health coverage.

That claim is also the subject of a lawsuit in federal court.

The White House, however, remains unimpressed by the Republican claim.

"The Department of Justice ... has made clear we have a permanent appropriation for this," Canegallo says.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Obama Renews Call For A 'Public Option' In Federal Health Law

NPR Health Blog - Mon, 07/11/2016 - 5:01pm

President Obama speaks in Dallas in 2013 about the technical problems that affected the initial rollout of the Affordable Care Act. Now, citing the law's success, he is urging Congress to expand the insurance offerings.

Brendan Smialowski/AFP/Getty Images

President Obama on Monday called on Congress to revisit the controversial idea of providing a government-run insurance plan as part of the offerings under the Affordable Care Act.

What's been described as the "public option" was jettisoned from the health law in 2009 by a handful of conservative Democrats in the Senate. Every Democrat's vote was needed to pass the bill in the face of unanimous Republican opposition.

But in a "special communication" article published Monday on the website of JAMA, the American Medical Association's top journal, the president says a lack of competition among insurance plan offerings in some regions may warrant a new look.

"Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited," Obama writes.

The president calls on Congress to take more steps to rein in the cost of prescription drugs and make government assistance more generous for those who still cannot afford health coverage; he also urges the 19 states that have not yet expanded the Medicaid program under the health law to do so.

The public option has been a point of controversy from the start. It was included in the version of the health law passed by the House of Representatives, and had support from most Democrats in the Senate, before it was dropped. Many liberals hoped — and conservatives feared — that having the government provide insurance alongside private companies would be a step toward a fully government-run system.

Presumptive Democratic presidential nominee Hillary Clinton — under pressure from Sen. Bernie Sanders' call for a single-payer government system — in February endorsed the idea of including a public option to allow people age 55 and older to purchase Medicare coverage.

On Saturday, as part of a deal with Sanders, Clinton announced she will also "pursue efforts to give Americans in every state in the country the choice of a public-option insurance plan," which is broader than what Obama is endorsing.

But even if Clinton wins and the Democrats take back control of Congress in November, a public option remains a political long shot.

Obama's article, titled "United States Health Care Reform: Progress to Date and Next Steps," is apparently the first by a sitting president to be published by the prestigious medical journal.

Along with these recommendations for further action, Obama's article includes a justification for the federal health law and statistics on how its implementation has improved insurance coverage for patients and improved health care quality.

Kristie Canegallo, the White House deputy chief of staff for implementation, says the article grew out of a comprehensive review of the law that the president requested from his staff late last year.

The review was to look at "what's working, what's not, and what we should do about it," Canegallo says. Upon receiving the review, she adds, Obama "thought it was important to share some of this publicly."

Among those parts of the law the administration says are working are the coverage provisions. "The number of uninsured individuals in the United States has declined from 49 million in 2010 to 29 million in 2015," the president writes.

The article also says that the health law has played a substantial role in slowing the rate of health spending.

"While the Great Recession and other factors played a role in recent trends, the [president's] Council of Economic Advisers has found evidence that the reforms introduced by the ACA helped both slow health care costs growth and drive improvements in the quality of care," says the article.

Jason Furman, chairman of the council, says the continuing slow growth in health spending so many years out from the recession makes the argument by some other economists that the turndown in the U.S. economy was mostly responsible for the slowing of health spending "absurd at this point."

While most of Obama's journal article is a chart-driven, footnoted recitation of the impact of the health law, he does use his perch to suggest that the current state of politics in Washington threatens progress going forward.

"Any change is difficult, but it is especially difficult in the face of hyperpartisanship," he writes. "Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported."

Republicans are continuing their assault on the health law. Just last week, two House committees released a joint investigative report and held two hearings asserting that the administration is illegally providing funds to help lower-income individuals pay for their health coverage.

That claim is also the subject of a lawsuit in federal court.

The White House, however, remains unimpressed by the Republican claim.

"The Department of Justice ... has made clear we have a permanent appropriation for this," Canegallo says.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Sick? People Say They Still Go To Work, Even When They Shouldn't

NPR Health Blog - Mon, 07/11/2016 - 2:17pm
Sick? People Say They Still Go To Work, Even When They Shouldn't Listen · 3:49 3:49 Toggle more options
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July 11, 20162:17 PM ET Heard on All Things Considered Vidhya Nagarajan for NPR

A majority of working adults say they still go to work when they have a cold or the flu. There are some jobs where doing that can have a big effect on health.

At least half of people who work in very public places, like hospitals and restaurants, report going to work when they have a cold or the flu. Those were among the findings of a poll conducted by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

They are some of the last people you'd want to go to work sick, because they tend to have a lot of contact with people. And that helps spread disease.

"It's one of the biggest food safety problems that there is, and we've known about it forever," says Kirk Smith, who oversees foodborne outbreak investigations with the Minnesota Department of Health. But he says it's really hard to get people to stop doing it.

When it comes to food handling, there's one illness that's particularly concerning: norovirus. "It is by far the most common cause of foodborne illness," says Smith. According to the Centers for Disease Control and Prevention, the virus is responsible for 35 percent of them.

That's because there are billions of virus particles per gram in stool and vomit. It only takes about 20 of those to get someone sick. And norovirus can hitchhike from surface to surface. It takes a high concentration of bleach to kill it.

"And so it just takes microcontamination of your hands, if you don't do a perfect job washing, to be able to contaminate food with enough of the virus to infect lots and lots of people," says Smith.

The same virus has plagued restaurant customers across the country. Last winter, 140 people — including much of the Boston College basketball team — got sick from eating at a Chipotle in Boston where one person had gone to work sick.

"It's definitely the norm to go into work sick. That's what I and most of my co-workers usually do," says Anthony Peeples. He used to work at an Olive Garden restaurant. Now he's a bartender at a casino in Michigan City, Ind.

Workers clean a closed Chipotle restaurant in Boston in December after customers became infected with norovirus.

Suzanne Kreiter/Boston Globe via Getty Images

At Olive Garden, he says, he was in a bind when he got sick, because he didn't have any paid sick leave.

"I don't think anybody really wants to go out there and get people sick or let alone work when they're miserable, but you have to," he says, "Or else you're not going to be able to pay your electricity or water or your rent."

The Food and Drug Administration has something called the Food Code that says food workers need to stay home 24 hours after their symptoms go away, but not all states have adopted the rule.

The CDC has found that 1 in 5 food service workers has reported working while sick with vomiting and diarrhea.

People don't want to leave their colleagues in the lurch, says Laura Brown, a behavioral scientist with the CDC's National Center for Environmental Health.

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She and her colleagues interviewed employees at about 500 restaurants in nine different states and then calculated which factors were most strongly linked to people going to work sick.

"Forty percent of workers did say to us that they'd worked while sick in the past because they wouldn't get paid," Brown says. "But when we look at the data statistically, that doesn't really seem to be a large driving factor in whether or not people actually work when they're sick."

A lot of them went to work because they were worried about losing their jobs if they didn't show. And there was another thing. "We found that workers who were concerned about leaving their co-workers short-staffed were more likely to say they'd worked while sick," Brown says.

Likewise, those who worked in places that had backup options — like on-call workers to fill in for sick staff — were less likely to work while sick. So the biggest factor, Brown says, was that "the workers are concerned about their co-workers having to work a man down."

NPR's poll also found that it isn't always money that drives people to work when they should stay home.

Adults in low-paying jobs are more likely to say they go to work ill — but about half of those in high-paying jobs are, too.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Webcast: Your Workplace And Your Health

NPR Health Blog - Mon, 07/11/2016 - 11:23am
Harvard T.H. Chan School of Public Health YouTube

Your workplace may be affecting your health — for better or worse.

It can raise your stress level and affect your eating and sleeping habits. Negative impacts from work may arise from concern about such things as workplace violence, toxic exposures and a bullying boss.

Some companies have expansive programs to eliminate these problems and help workers improve health. But are workers taking advantage of them?

A new poll conducted by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health and released Monday, explores these issues and details the effect your workplace can have on your health.

One of the highlights of our coverage of the poll's findings includes a discussion with workplace and health experts at The Forum at the Harvard Chan school.

The discussion was livestreamed at 12 pm ET Monday and will be archived here.

Some of the issues discussed: What are the factors that create a stressful workplace? What are some of the successful strategies that businesses have used to lower stress and foster better health? Is a broader, more communitywide approach needed to improve wellness?

Joe Neel, deputy senior supervising editor on NPR's Science Desk, moderatef the discussion with:

  • John Quelch, professor of business administration, Harvard Business School, and professor in the department of health policy and management, Harvard T.H. Chan School of Public Health
  • Marjorie Paloma, director at the Robert Wood Johnson Foundation
  • Glorian Sorensen, professor of social and behavioral sciences and principal investigator, Center for Work, Health and Wellbeing, Harvard T.H. Chan School of Public Health
  • Robert Blendon, professor of health policy and political analysis, Harvard T.H. Chan School of Public Health and Harvard Kennedy School
Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Hassle Of Being A Patient Can Turn Into A Crisis Without Sick Leave

NPR Health Blog - Mon, 07/11/2016 - 4:31am
Hassle Of Being A Patient Can Turn Into A Crisis Without Sick Leave Listen · 6:12 6:12 Toggle more options
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July 11, 20164:31 AM ET Heard on Morning Edition Raymond Biesinger for NPR

Here's a typical scenario when you have a medical problem. You go to your doctor's office, then have to run across town to a lab for a blood test and then you also have to get an appointment for an X-ray or MRI. There's a good chance this will all require a phone call — or a lot of phones calls — with your insurance company.

It's a hassle and it's time-consuming.

But for many people it's even worse than that.

That's because about a third of working adults say their jobs don't come with paid sick leave, according to results from the latest poll by NPR, The Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

And for some of those people, taking care of their health needs can lead to a financial crisis.

Take Valerie Hesse, a catering chef in New Orleans. "I've had allergies — pollen and dust and everything else — since I was a kid," she tells Shots. "Over the years it got to the point where I was having frequent sinusitis, sinus infections, occasional bronchitis."

Hesse went to the doctor a lot to deal with sinus and ear infections. She tried to schedule the appointments around her work hours, and sometimes her doctor would give her a break and prescribe antibiotics over the phone.

But sometimes she'd be called in at the last minute. Or she'd have to work an extra shift.

"I had to reschedule, postpone, skip," she says. "I wasn't gonna get paid and you gotta work."

Over time, the constant congestion and infections were damaging her hearing, so last year Hesse decided to have surgery to fix the problem. Recovery took weeks.

By the time she was able to get back to work, she had a reputation as sickly and unreliable.

"The owner of the company told me that he had decided to make a management change," she says. "I was let go."

Hesse is now living off savings as she makes plans to open her own catering business. She says she needs to be her own boss to be able to take care of herself.

Our poll found that 32 percent of people in the U.S. are like Hesse. They don't get any paid sick days. And 24 percent have no paid vacation time.

So unless they work odd hours, people without either benefit lose income if they want to take care of their health.

That's a real problem, but it's not the only consequence of what Dr. Victor Montori of the Mayo Clinic refers to as the "work" of being a patient.

He says the health care system is designed for the convenience of doctors — and the result is that patients find themselves running to doctor's offices, labs, imaging centers and back, often carrying their records along with them.

"That is not an organization of care that started by thinking, 'How do we meet the needs of the patients?' " Montori says.

The current setup was created at a time when people saw a doctor for an injury or infection. By contrast, today most people by middle age are dealing with a chronic condition that requires regular care.

So, like Hesse, they have to fit health care into their daily lives. And the system that requires a patient to leave work, go to the doctor, go elsewhere for tests and then go to a pharmacy, isn't very useful, Montori says.

"For people with chronic conditions, the health care system is blind to their context," Montori says. "In particular, it's blind to the work of being a patient and the capacity that people have to shoulder that work and make it happen."

And if patients don't do everything right — if they don't get their tests, or refill their medications on time, or go to follow-up appointments — they are deemed by the health care establishment to be "noncompliant," he says.

"We just decide that it's the character of the patient that is to blame and move on," Montori says. "Rather than reviewing our own behavior as a health care system and see how is it that we have created so much work for people that they no longer can do it."

Montori and his colleagues are now reviewing that behavior and trying to determine how to make the health care system more responsive. One approach is to put health care providers in schools and workplaces and to make them available during evenings or weekends.

"Once we start thinking about meeting the needs of people, the first thing we say is, 'Where are these people, and how can we start thinking about meeting their needs where they are?' " Montori says. "Can the kid not get the asthma care at school? These kids are at school for hours and hours and hours."

Many doctors say it's not just the system they created that is complicated. It's also complex rules imposed by Medicare and insurance companies that make being a patient harder.

"You can't do multiple procedures at the same time or on the same day without having the second procedure's payment cut," says Kristine Longshore, an ophthalmologist in Doylestown, Pa.

If she wants to operate on both eyes of a patient, she'll be paid less if she does both eyes at the same time than on different days.

Sometimes, she says, she's not allowed to do two procedures on the same day at all.

"I cannot image the optic nerves and macula on the same day even if the patient happens to have both glaucoma and macular degeneration," she says. If she does, Medicare won't pay for one of them.

"And that's a real hardship for patients. They may have to have the right eye treated and come back the following week to have the left eye treated," she says.

Longshore says insurers, including Medicare, are already cutting payments to doctors. With their incomes shrinking, doctors may be reluctant to earn even less by doing two procedures at the same appointment.

It's those sorts of insurance practices that make getting health care cumbersome for Tammy Davenport, who lives outside Houston.

She recently needed an MRI to determine why a year-old ankle injury wasn't healing properly. Davenport has hemophilia, a disorder where people bleed excessively, often into their joints.

Last year she fell down some stairs and landed on the ankle. She ended up in the emergency room and could barely walk for a month. Now, 15 months later, she was still in enormous pain, so she went to her doctor and he ordered the test.

"It took me eight hours on the phone, one full day of work, to get an appointment for an MRI within 15 to 20 minutes from our house," she says.

To control costs, Davenport's insurance company requires an outside contractor to approve the doctor's authorization for the test. A second contractor then schedules the test. That company works with only three MRI centers, and all of them were more than 90 minutes from her home.

Davenport says there were several within a few miles on her insurance company's website, but the company refused to work with them. After hours calling different people — all while she was supposed to be working — she got the appointment.

"Its all just a random phone tag that you have to go through just trying to get an answer to a question," she says.

But there are signs of change. The health care system is shifting in ways that may make things easier for patients, says Gail Wilensky, an economist who was head of Medicare and Medicaid under the first President Bush.

She says doctors are leaving behind individual practices and joining health care groups that combine specialties and services under the same roof. "The general move toward better integration of care can be a major improvement and convenience for the patient," she says.

But that transition will take time. It requires doctors and health systems to rethink how they've been doing their work for decades.

In the meantime, people like Hesse will continue to have to choose between getting healthy and getting paid.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Work Can Be A Stressful And Dangerous Place For Many

NPR Health Blog - Mon, 07/11/2016 - 12:01am

Employers' efforts to reduce stress get low grades in a new poll by NPR, the Robert Wood Johnson Foundation and Harvard's T.H. Chan School of Public Health.

In particular, among those working adults who say they've experienced a great deal of stress at work in the past 12 months, the vast majority, 85 percent, rate the efforts of their workplace to reduce stress as fair or poor.

Overall, 43 percent of working adults told us their job negatively affects their stress levels. Others said their job negatively affects their eating habits (28 percent), sleeping habits (27 percent) and weight (22 percent).

"The takeaway here is that job No. 1 for U.S. employers is to reduce stress in the workplace," said Robert J. Blendon, professor of health policy and political analysis at the Harvard Chan School, who directed the survey. It included interviews with 1,601 workers, by landline and cellphone. The margin of error is 2.9 percentage points.

The poll also found that only about half of working adults have workplaces that offer wellness or health-improvement programs. About 1 in 4 rate their workplace as fair or poor in providing a healthy work environment, and more than 4 in 10 rate their workplace as fair or poor in providing opportunities for physical exercise or healthful food options at work.

About 1 in 5 working adults (22 percent) say something at their job may be harmful to their health, with chemicals and contaminants topping the list for 30 percent of those who have concerns about their workplace. We found 43 percent of construction or outdoor workers and 34 percent in medical jobs have health concerns in the workplace.

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One of the obvious reasons for stress in the workplace may be overwork.

As is detailed in the poll report, working adults in our sample lived up to America's reputation for being workaholics, with almost two-thirds of them saying they often or sometimes work overtime or on the weekends. About 1 in 5 say they work 50 or more hours each week in their main job.

Of course, taking breaks and vacations may help relieve stress. But our survey found that even among those who get paid vacation days, less than half use all or most of the days they earned in the past year. And when they do take vacation, 43 percent of high-pay workers say they often or sometimes work on vacation, with 28 percent of average-pay workers and 18 percent of low-pay workers saying the same.

Why do Americans work so much? A majority (56 percent) of people working 50-plus hours a week in their main job say they do so because "it's important for their career to work longer hours." Half (50 percent) say they do so because they "enjoy it," and 37 percent say they "need the money."

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These responses may be reflected somewhat in the chart below, where higher-paid workers more frequently say they work 50-plus hours, versus lower-pay workers.

It's a similar story when it comes to sick leave. A majority of workers who get paid sick days and who did not use them all (73 percent) say they weren't sick enough to use all of their days. More than one-third (37 percent) say a major reason why they didn't take all their sick days is that they want to save them for another time, while 28 percent say there wouldn't be enough people to cover their work.

Twenty percent of those who didn't use all their sick pay say their workload made it too hard to take sick days, while another 20 percent say working more (and not taking sick leave) would help them get ahead at work.

Overall, just 16 percent of workers have used all of their paid sick days in the past year, while 6 percent used most, 45 percent used only some and 32 percent used none.

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And then there are those who get no sick leave at all. While two-thirds of full- or part-time employed workers overall say their workplace offers them paid sick days, just 38 percent of workers in low-pay jobs say they get paid sick leave. Those ranking lowest in paid sick leave were those in construction/outdoor jobs (42 percent) and restaurant jobs (22 percent).

Does reluctance to use paid leave lead workers to go to work sick? A majority of working adults in our survey say they do just that. Of interest: Half of restaurant workers and more than half of workers in medical jobs say they still go to work always or most of the time when they have a cold or the flu.

But the connection between paid leave and going to work is fuzzy. Laura Brown, who studies the issue at the Centers for Disease Control and Prevention, tells NPR's Rae Ellen Bichell that their studies don't show a strong link between the two.

"Forty percent of workers did say to us that they'd worked while sick in the past because they wouldn't get paid if they didn't work," she says. "But when we look at the data statistically, that doesn't really seem to be a large driving factor in whether or not people actually work when they're sick."

Leaving their co-workers short-staffed was a more likely reason for going to work while sick, she says.

In one of the first stories in our series, "The Workplace and Your Health," we will look at the issue of juggling medical care with work in more depth, and how the lack of paid leave can lead to more medical problems. In another story, we'll hear more about the stress that people with disabilities experience at work; over 6 in 10 (62 percent) say their job has a bad impact on their stress level, compared with 41 percent of workers without disabilities.

Our poll found many working adults have concerns about safety at work. As the chart below shows, those in low-paying jobs were more likely than those in high-paying jobs to say they often or sometimes face potentially dangerous situations.

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It's unclear from the survey why so many restaurant and retail outlet workers say they often or sometimes face potentially dangerous situations on the job. But we did find that, overall, 19 percent of working adults have seen or heard of violence against employees in their workplace.

And while shift workers (54 percent) are more likely than day workers (38 percent) to say they face danger, a significant proportion of shift workers say they do it because it is better for their lifestyle (39 percent) and/or it makes it easier to care for the family (38 percent). Half say better pay associated with shift work is the reason they do it.

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But it may be that the workplace is getting safer overall. Among those who ever face potentially dangerous situations at work, almost three-quarters (73 percent) believe their workplace is actively working to reduce these dangerous conditions.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Hope Still Races Ahead Of Evidence In Magnet Treatment For Autism

NPR Health Blog - Sat, 07/09/2016 - 7:00am
Katherine Streeter for NPR

The story is a familiar one: the saga of a loving parent's quest to save a child. This time it's about the mother of a boy with autism. The mother scours the medical literature in search of any kind of treatment, however far-fetched and experimental. She finds one that seems promising, something involving magnetic fields, and moves mountains to get it for her son as part of a research protocol.

Then, seeing that it helps, she devotes herself to getting more of it. Ultimately the mother starts a foundation to promote research into the new treatment, hoping to prove its value and one day make it part of standard care, not just for her son but for other children with autism, too.

This particular version of the story, though, is tinged with irony. The treatment in this case is transcranial magnetic stimulation, and the mother is a Minneapolis woman named Kim Hollingsworth Taylor. In 2012, Taylor's son, age 14 at the time and on the high-functioning end of the autism spectrum, was part of a trial of TMS that seemed to relieve a few of his autism symptoms for several days, making him able to read social cues more accurately and to complete cognitive tasks in far less time than before.

Additional Information: Beware Your Frame Of Reference

We all carry an invisible frame of reference in our heads that filters our experience, shaping the way we see each other and the world. This week's episode of the NPR podcast and show Invisibilia explores what happens when that frame of reference gets turned upside down — in one case by a brief encounter with a powerful magnet.

Pleased with the results, Taylor found a way the following year for her son to get more treatments in Boston, twice a week over the course of 10 weeks, even though TMS had not been approved by the Food and Drug Administration for autism symptoms (and still has not).

During this time, Taylor says, her son's autism symptoms disappeared, and he went from being a boy with no friends to being a boy who was asked to the homecoming dance by four different girls. The change thrilled her so much that she started a small nonprofit to advance research into the use of TMS for autism. Taylor, who has a background as a financial analyst in the medical technology industry, called the foundation Clearly Present, the phrase her son used to describe how he felt after treatment. "It's like there's more of me here now," he told her.

But the benefits began to fade after just a few months. Three years after his last treatment, Taylor's now 18-year-old son is back to where he was before he started on TMS. And he says he doesn't want to try it again if it means again disrupting the family life and moving to Boston with his father for another three-month stretch.

So here is Taylor, committed to organizing scientific conferences and soliciting research funding through the Clearly Present Foundation, with the personal impetus for her labors having disappeared.

"Like most people I would crawl on broken glass to make things a little better for my kid," Taylor said in a recent phone interview. So she finds it "profoundly sad" that there's no place closer to home that could offer TMS to her son — and frustrating to be in the midst of a demanding volunteer project that, for now at least, doesn't seem likely to help her own child.

Shots - Health News What An Hour Of Emotion Makes Visible

In an article on TMS for Spectrum, a Web magazine about autism science, the writer Lydia Denworth called the story of the Clearly Present Foundation "a cautionary tale for anyone who reads too much into TMS' benefits." Another cautionary tale is featured in the latest episode of NPR's podcast and program Invisibilia, about a middle-aged physician on the autism spectrum who also tried TMS. The treatment, which the woman (also named Kim, but not related to Taylor) underwent twice, enabled her to perceive subtle emotions in others for the first time in her life. Then, after less than an hour, that insight disappeared.

How did she feel about getting this brief insight into how most people experience feelings? "It could be that you would get a glimpse of this and you couldn't have it, and it would be completely heartbreaking and you couldn't get over it," she told Invisibilia host Alix Spiegel. But after reflection, the physician told Spiegel, her feelings were mixed — depression, yes, but also gratitude that she'd had a chance to gain a deeper understanding of what it means to be human.

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Autism is a developmental disorder that can be disabling, and there's no cure. That makes families uniquely vulnerable to the potential of untested treatment. The fear is that TMS could turn out to be the latest in a long string of untested or off-label treatments for autism, from chelation therapy to hyperbaric oxygen chambers to gluten-free diets, that desperate parents have been spending money on for decades.

None of these treatments has proven beneficial in clinical trials, and some have actually caused harm. FDA officials worry that even if a treatment is relatively safe, it could still divert precious resources away from proven treatments, such as behavioral interventions and certain drugs.

Companies promoting untested approaches face "possible legal action if they continue to make false or misleading claims about products and therapies claiming to treat or cure autism," the FDA wrote in a consumer bulletin in 2014. "Some of these so-called therapies carry significant health risks."

It's easy to understand the enthusiasm for a treatment like TMS, which is noninvasive, nonpharmacological and already has FDA clearance for one condition — severe depression that doesn't respond to other treatments. It has few known side effects, though it has been shown, in very rare cases, to cause seizures.

The treatment involves placing a relatively small and very powerful electromagnet on the scalp, and sending pulses of magnetic waves directly into the brain to activate or deactivate particular neurons. It has been used experimentally in autism, mostly in hopes of developing a better diagnostic tool. But as news percolates of this research application, more and more people want to try it for themselves or their children.

But for autism, the science of TMS treatment is, according to researcher Lindsay Oberman, "still in its infancy."

"I know it's easy to get overly optimistic given the media coverage and web posts about the remarkable responses some people with autism have reported after participating in a TMS study," Oberman, a research psychologist at Brown University and Bradley Hospital in Rhode Island, wrote last March in a blog post for the advocacy group Autism Speaks.

But those studies have been very few — just 13 in the medical literature to date — and they tend to focus on only a select group of subjects: adults, generally male, who are high-functioning and do not have epilepsy. It's risky, then, to generalize to how TMS would affect women or children with autism, or people with more severe symptoms.

Author and autism activist John Elder Robison took part in a study of TMS (transcranial magnetic stimulation) at Boston's Beth Israel Hospital in March.

Keith Bedford/Boston Globe via Getty Images

"I caution against drawing conclusions from the preliminary results of the TMS studies that I and others have conducted," wrote Oberman in her blog post.

Among those 13 trials of TMS for autism, which involve fewer than 200 people altogether, only one is a double-blind, randomized trial — the type of trial designed to rule out the so-called placebo effect (improvements that occur because subjects expect them to).

In the double-blind study, conducted in Australia on 28 high-functioning adults diagnosed with autism or Asperger's syndrome, the 15 people in the treatment group showed some improvement, compared with the 13 controls, in terms of better social skills and reduced anxiety, both immediately after the treatment and at the one-month follow-up.

The real excitement over TMS for autism, however, does not come from the medical literature. It comes from popular testimonials of people on the autism spectrum who credit TMS for heightening their emotional sensitivity and leading to fewer obsessions, fewer repetitive actions and improved social skills.

John Elder Robison, an author and autism activist, describes his own experience in his latest book, Switched On: A Memoir of Brain Change and Emotional Awakening. The alterations of TMS were life-affirming, he writes, but they were tinged with sadness, too, because his insights into others' emotions showed him how troubled most people's inner lives really are.

"Before the TMS, I had fantasized that the emotional cues I was missing in my autism would bring me closer to people," Robison wrote earlier this year in The New York Times. "The reality was very different. The signals I now picked up about what my fellow humans were feeling overwhelmed me. They seemed scared, alarmed, worried and even greedy. The beauty I envisioned was nowhere to be found."

But while Robison says his heightened emotions have generally persisted in the eight years since his first treatment, even his doctors say his response is unusually robust.

It's easy to see why parents would grab at cures that promise to bring back their sons and daughters, to give their children a voice, stop them from self-harm, or offer them a chance at friendship and independence. But quite apart from the question of whether the traits of autism are symptoms to be treated or differences to be embraced — a debate at the heart of the neurodiversity movement — Oberman says it's too soon to institute TMS as a treatment, especially for children, whose brains are still developing.

It's difficult to predict the long-term consequences for children of routinely disrupting their brain activity. And it's hard to know, for children and adults alike, the details of how best to offer TMS for autism: how often it should be used, for how long a period, in which regions of the brain, and for what purposes.

"There are still many things that we do not understand about how the developing brain responds to TMS or any form of neural intervention," Oberman told me by email this week. "And if the goal with TMS is to 'rewire' or affect the connectivity of the brain in order to improve symptoms, we first have to understand what degree of connectivity and wiring is healthy at any given age, and what type of stimulation will improve the functioning of these areas."

In other words, scientific evidence about the efficacy of TMS in autism is not in yet, and it's accumulating the way most scientific evidence does: with painful slowness.

Among the still-unanswered questions about TMS is how it works and which autistic behaviors it best targets. Put 10 clinicians in a room, Oberman says, and you're likely to get 10 different answers. Her own research interest is in social communication, she says, but other symptoms — poor executive functioning, depression, irritability, poor language skills — are just as likely to be affected.

"We've been using TMS for adults with autism who have other co-morbid conditions such as obsessive-compulsive disorder and depression," says Eric Hollander, director of the Autism and OCD Spectrum Program at Montefiore Medical Center and the Albert Einstein College of Medicine in the Bronx. "And we've had good luck in terms of reducing the severity of some compulsive behaviors, as well as anxiety."

Hollander has found TMS useful for relieving such autism symptoms as agitation, self-injury, and behavioral rigidity. But he says many questions about TMS for autism are still unanswered, including which brain regions to target, the optimal frequency and duration of treatment, and the best schedule for booster therapy for long-term maintenance.

In addition to all these questions about how TMS should be used, scientists don't really know much about who the best candidates for TMS are. Is it best aimed at those on the high-functioning end of the spectrum? Only for adults? Only for those without epilepsy or other co-existing problems?

And what are the ethical implications of recommending TMS for a use not approved by the FDA? Even though it is legal (doctors can prescribe any FDA-approved drug or device for any purpose, not only the purpose for which it was originally approved), that does not make it the right thing to do.

One way to answer these questions is through a multicenter therapeutic trial of TMS for autism, something that Taylor and the Clearly Present Foundation have been trying to help organize. But clinical trials are expensive and would require a major grant, which members of the coalition of researchers Taylor has assembled, known as the TMS Therapy for Autism Consensus Group, have spent the past two years trying to obtain. They're talking now about first coordinating a number of pilot studies at individual institutions, on the way to gearing up to a large-scale, multicenter clinical trial.

There are already a few studies of TMS and autism underway: One in Canada is looking for improvement in executive function in 50 adolescents and young adults; another in France is looking for changes in social cognition in 60 adults; and one in Israel (the one most relevant to children) is looking for changes in social interaction in 20 children and adolescents who have autism or an intellectual disability or both.

In the meantime, Oberman says the only safe way to receive TMS for autism, for adults and children alike, is by being part of a research trial — which means going to clinicaltrials.gov to volunteer to be a study subject.

"I would not recommend receiving TMS 'treatments' from a clinician outside of a research study," she says, "as there is no standard protocol, nor strong evidence that any given protocol is likely to lead to long-term improvements in symptoms of autism spectrum disorder. Anyone who tells you otherwise is simply misleading you."

Science writer Robin Marantz Henig is a contributing writer for The New York Times Magazine and the author of nine books. She also serves on the board of advisers for Spectrum magazine.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

What An Hour Of Emotion Makes Visible

NPR Health Blog - Fri, 07/08/2016 - 3:00am
Kristen Uroda for NPR

Editor's note: This is an excerpt from the latest episode of the Invisibilia podcast and program, which is broadcast on participating public radio stations.

Until she was 54 years old, Kim was totally unaware that there were things in the world she couldn't see.

"This was the whole problem," Kim says. "I had no clue what the problem was."

All Kim knew was that over and over and over again the world didn't respond the way she expected. People would say things and do things that seemed completely unrelated to what was actually going on. It happened all the time.

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Once, as a kid at summer camp, she saw two girls trying to put up a sail on a sailboat. "And I'm always really good at doing that kind of stuff, and I looked at them and I could see what their problem was," she says. And so she walked up to them, explained that she could help, could show them how to do it.

"And they were mad at me," she says. The girls started screaming, telling her to go away.

"It was so strange," she remembers. "It was like ... why would they be mad when I'm trying to help them? That makes absolutely no sense. I don't understand that."

That was in 1966, when Kim was 12. More than 40 years later, after a researcher spent 30 minutes pressing a fancy magnet to the top of her head, Kim would finally experience firsthand the critical element of the sailing scene that she had missed in 1966: the subtle emotions swirling around.

"I didn't realize that the overall context was that these people are having a relationship," Kim says. "I didn't see things that way. What I would see is the physical aspect of it: There are two people here; they're on a boat. The boat needs to have the sail go up before it they can sail; therefore, they need help with the sail."

Now she realizes there was much more happening. It wasn't just that "those two people are talking." They were friends, enjoying each other's company. That was the primary event, not getting ready to sail.

We all carry in our heads invisible frames of reference that filter our experience and shape the way we see the world around us. Those frames are the product of many things — our cultural experience, our assumptions, but also our biology and the way the biology of our particular mind focuses our attention in the world.

Kim's brain is not great at seeing emotion. When she looks out at the world she physically sees all the things that most people see, but with much of the emotion subtracted. She sees the same tables, the planes, the trees ... the people moving back and forth. But the feelings — particularly the subtle ones — are invisible. Though for most of her life she didn't realize that.

"This is the interesting thing," Kim says. "We believe our senses, so I didn't know I was missing anything. If I'm seeing people talking and it simply looks like people are talking, why should I think that they might be feeling angry or sad or anything, if I'm not sensing that?"

This is the story of how Kim was given a window into the world she couldn't see and how that changed her frame of reference. It was a small window — it only lasted 90 minutes. But it turns out that 90 minutes is more than enough time to unsettle a life. Because all you need to do to unsettle a life is expose it to a new frame of reference.

Before the magnet experiment

Kim grew up in Pennsylvania Dutch Country with middle-class parents and four younger brothers. Talking to her, you get the sense that growing up she could see some emotions in other people, but her read of feelings was pretty basic. She knew that smiling meant someone was happy, that crying meant they were sad, and that people who spoke in loud voices were angry. And she could usually tell if someone was puzzled by something, but emotions more subtle than those were difficult.

Basically, although internally Kim experienced the exact same things any of us do — the anger and love and frustration — she had no way to interpret her emotions, in part because her understanding of emotion in the world around her was so limited.

Of course, the world we live in demands a high amount of emotional dexterity. Emotionally, you need to be fluent and flexible, able to read the world around you and manage how you feel. And if you're not that way, things can get painful quickly. So it's no surprise that things got painful for Kim. There was taunting and name calling when she was a kid that progressed to pushing and kicking, and then to more harmful physical acts.

"The worst thing that ever happened was [when] I was at summer camp," she says. "It was one of those summer camps where there were maybe upper-middle-class kids that were cliquish. And I don't know what I did — I have no idea — but they actually bound and gagged me and took me out of the cabin at night in the rain and, you know, put me outside. And it was just awful."

Kim is crying as she explains what happened, still totally mystified. What had she done that caused them to behave this way? "I had no idea," she says. "I thought they were my friends. I had no idea they weren't my friends. I didn't know I was doing something they didn't like."

For a long time, this kind of bullying was part of Kim's day-to-day life. "I would shut myself in my room and just cry and kick the wall and be totally distressed and not know what to do."

Kim understood from the other kids that there was something wrong with her, but she had no idea what it was. She continued to believe that she was seeing what everyone else saw, and so couldn't fathom that her responses weren't the most appropriate and logical. So, on a certain level, she began to dismiss the people around her.

"I thought, 'Well, these people are crazy,' " she says. "What I do makes a whole lot more sense, you know, so I must be better than them in some ways. I'm smarter. I can figure things out. They don't know how to put up a sail on a sailboat; I can do that."

And, since Kim is a very bright person, she started using her intellect to make her life easier. It started at summer camp. She decided to be one of the cool kids at camp, and her strategy was to pretend to be bad. So Kim started swearing, and put snakes in the counselor's sleeping bag. The strategy worked beautifully.

"I didn't get bullied!" she says. "I didn't like being bad, 'cause that's not who I am. But it felt so good to feel like I could actually have some kind of communication with these other kids and get along with them on some level. And that was actually a really important experience, because it gave me hope that, well, maybe if I do something differently, there might be a different result."

After ninth grade, Kim moved to a new school, and she used the opportunity to develop new strategies, which also worked out well. Then there was college — also good — and medical school.

In much of her life Kim was able to passto function more or less as people who could see emotions did. She had friends and meaningful work, though there were areas of her life she couldn't fully master, like romance.

"Just that whole kind of give and take — what's going on with me, what's bothering me or what isn't bothering me, or what do I like or what do I not like, what do I want or not want, and what do you want and not want" — was very hard, she says. "It's so much easier when you call your friend and you say, 'Do you want to play racquetball?' And they say 'yes' or 'no.' "

So, Kim mostly stayed away from romance. And things were more or less fine. In fact it wasn't until later, after she graduated from medical school and had established her practice as a doctor, that her inability to see emotions became a big issue again. It surfaced in the place she least expected: in her office, working with her medical assistant.

"I would go through medical assistants left and right," she says. "It was awful. One year I went through seven medical assistants."

Again, Kim decided to think her way out of the problem. One day, while talking to her brother on the phone, she happened on a promising new approach.

"I called him at work," Kim remembers. "And he said, 'Oh, I was just talking to my secretary about her weekend.' And I said, 'You were what? Why would you do that?' And he said, "I always do that; I just spend some time socializing with her and getting to know her and making her feel like part of the business. I probably talk to her, like, 10 minutes a day.' "

Kim was surprised, but intrigued.

"I said, 'Really! I would never have considered that as an option.' "

So off Kim set to incorporate small talk into her daily routine. But that didn't fix the problem. Her practice was suffering. The constant upheaval was a huge drain.

Then, one day in 2008, someone close to her was diagnosed with what was at the time called Asperger's syndrome — it's now described as a "high functioning" form of autism spectrum disorder. So Kim decided to learn more about the topic.

She picked up a book and started reading.

"Oh my God," she remembers thinking after just a few sentences. "This is the way I think! This is scary."

She went online, found a test that measured Asperger's, and clicked through the checklist of items: She was not good at social chitchat, but did like to collect information about different categories of things. She found it difficult to work out people's intentions and was often told that she kept going on and on about the same thing.

Staring into the screen, it suddenly dawned on Kim that she could have Asperger's — something no one before had suggested.

"The diagnosis wasn't even available when I was going to school," she says.

The idea that she might have Asperger's terrified Kim. She was a successful person. A working doctor. A woman with friends. She didn't want to stir the pot.

So she decided to keep her likely diagnosis a secret, at least professionally, which is why NPR has agreed to use only Kim's first name in this story.

Still, because she was still struggling so much with her employee at work, Kim wanted to find out more about Asperger's. So she started attending an Asperger's support group near her home. And it was during one of these sessions that she heard about the thing that would change her life.

Someone in the group told her about research studies on Asperger's that were starting at Beth Israel Deaconess Medical Center in Boston.

"I thought, 'Well, this might be interesting,' " she says. " 'Maybe I'll learn something.' "

A magnet that acted like a switch

Lindsay Oberman is an experimental psychologist and assistant professor at Brown University now, but back in 2008 she was a postdoc at Harvard and part of the team conducting research on the brains of people with Asperger's. The idea was to investigate how a procedure called TMS affected this population.

TMS stands for transcranial magnetic stimulation. Basically, TMS uses an electromagnetic coil placed next to the scalp to send repeated magnetic pulses painlessly through the skull to stimulate certain brain cells. After a very short period of time (typically 30 minutes of rhythmic pulsing) the magnetic field is thought to activate a targeted region of the brain — just an inch or so beneath the coil.

Transcranial Magnetic Stimulation

The TMS procedure uses an electromagnet to painlessly stimulate or quiet certain regions of the brain temporarily.

Credit: Katherine Du for NPR

TMS is very much in the beginning stages of research as far as autism goes, according to scientists studying the technique. It's not ready for prime time as a treatment for autism, though the FDA has approved it as a treatment for major depression that doesn't respond to other therapies. Mostly, autism researchers like Oberman are still using the procedure to do small studies aimed at figuring out how best to point the magnet and where in the brain to point it. The experiment Kim heard about at the meeting of her Asperger's group was precisely that kind of preliminary experiment.

"The goal was not to treat Asperger's or autism syndrome," Oberman says of these studies.

In fact the goal of the study Kim showed up for in May 2008 was very modest. Oberman and her colleagues wanted to see if shooting the focused magnetic pulses through the skull at a certain part of the brain could change the way that people who have been diagnosed with Asperger's process language — their ability to pick up subtle shifts in inflection and tone of voice, for example, and how quickly they are able to read words and how they pronounce the words out loud.

As part of that research, before Kim was placed under the magnet she was given a battery of assessment tests. In one task the scientists displayed sentences on a computer and ask her to read the sentences out loud. The sentences were simple:

"Is this a holdup?"

"I don't drive a car; I drive a pickup truck."

"Did they make up?"

"This box is too heavy to pick up."

Kim read the sentences just as she had read so many sentences before. Then came the magnet. A small, flat device — maybe 10 inches long — was pushed gently against her scalp. With repeated clicks, it shot an invisible magnetic field in rhythmic bursts through her skull.

Kim remembers sitting under the magnet, wondering about the arm of the person whose job it was to physically press the magnet to her head. Were they tired? Shouldn't they be allowed to rest? She sat there for 30 minutes, the muscles in her face jumping with each click of the magnetic pulse.

Then Kim was given the exact same sentences to read aloud.

Is this a holdup?

This time, she says, that sentence seemed completely different.

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The first time, she says, she'd read it pretty much flat, "with a question mark at the end, so you raise your voice at the end of the sentence."

But after the magnet treatment she says, she felt the terror in those words. "It's like, 'Is this a hold up??!!' There was this sense of, oh my gosh, this would really be fearful, if someone was thinking they were really being held up!"

For the first time, with that sentence and others, Kim felt the emotion of words on a page. She was amazed: "What's happening?! Oh! This is really wild! I actually understand what's happening; I can feel it! I can hear it in my voice! Is this what I've been missing?"

Kim couldn't believe the transformation. The words meant so much more than ever before.

"They were conveying meaning and they were conveying emotion," she says. "And I saw that! I felt that! That was so remarkable! It was, 'Oh my gosh, this is so much more alive! It's so much more real, deeper, more meaningful!' "

"It's like black and white to color," Kim says. "It was a huge difference, and I saw it right away."

The effects were short-lived; Kim's ability to see words this way lasted less than an hour. By the time she drove home, it was gone — back to "black and white." But, in a certain way, that didn't matter, she says. Her life was changed. Kim had been given a completely new perspective.

Life with a new frame of reference

When Kim left the offices of Beth Israel Deaconess Medical Center that day she was physiologically the same person she'd been four hours earlier, when she went in. But she was different, too.

She went home that afternoon and sat on the couch in the same living room she'd left in the morning. Then it hit her: Her whole life, she'd not been the person she thought she was.

"One of the things that came up was that I realized I had been compensating for everything that I had done when I was young by telling myself that I was better than other people," she says. "That I was smarter, and the stuff they were doing was really stupid."

But that day on the couch, "that whole thing kind of came crashing down," Kim says. "Because, what was really clear here is that, in the ways that I thought I was better, I was not necessarily better. I was definitely different than most people. And I definitely had some issues with the way I processed things that were significantly impacting my life that I didn't really know about.

"I started getting really depressed."

For months afterward Kim felt hopeless. There was all this stuff that she had been missing — was still missing — and there was absolutely nothing she could do about it.

"There was a lot of grief," she remembers. "A lot of sadness."

Next came the second-guessing. At night, after a long day of work, she would lie in her bed reviewing the day — her interactions with her medical assistants, her conversations with her patients — and asked herself, "Did I do the wrong thing? How did I say that? Did I do that right? Did I do that wrong?"

It was endless.

Kim felt terrible. She wrote a letter to the researchers, telling them how grateful she was to have been in their study, but also, how she was struggling with depression. She yearned to see emotion in the same way again — in fact, reached out to the researchers to let her do more TMS. She assumed that, like before, the effects would be short-term. Researchers say there seems to be a 15- and 40-minute window of a change in perception, to the extent that it happens at all. But Kim still wanted it, and even offered to pay.

But they couldn't make that work. So, in August 2010, Kim went back to Beth Israel for another TMS experiment, and the effect of this one was even more dramatic.

Like the first study, this one was focused on language. But this time the researchers had Kim watch a series of short video vignettes, with actors playing different parts.

Kim vividly remembers watching the first one: "There was a guy sitting at a computer working," Kim explains, "and a woman walked up and said hi to him, and they exchanged pleasantries. And he said, 'John returned your DVDs.' And she said, 'OK, great.' And he said, 'Do you want to check them?' and she said yes."

Next, the woman in the video picks up the first DVD and opens it, Kim says. "And the camera shows that there's nothing in there. And then she picks up the second one and opens it and it's empty again. And the guy says, 'Are they OK?' And she says, 'Yup, they're OK.' And then she picks up the third one, and it's also empty and she puts it down. And the guy says, 'Would you lend him your DVDs again?' And she says, 'Sure I would lend them again.' "

"So I'm looking at this," Kim says, "and I'm thinking, 'Oh, my gosh! I can't believe that she'd be willing to lend him the DVDs again after they'd been returned empty! Wow! She's really a generous person!"

When the series of videos ended, the researchers again pressed the magnet to Kim's scalp, and for 30 minutes its sharp metal click beat in her ear. Then she watched the video about DVDs again.

"So, he walks up, they say hi, she opens the first video. It's empty. She's angry!" Kim suddenly realizes. "She slams it down! She opens the second one — she's angry! She slams it down. He says to her, 'Are they OK?' She says to him, in a very sarcastic tone of voice, 'Yes they're OK. Sure, I would lend them again' — clearly meaning, 'No way would I lend this guy any videos again!' "

Kim could not believe the difference after just a few pulses from the magnet.

"Everything that was intended in this went completely over my head, and now I saw it!" Kim says. "The body expression, the facial expression, the tone of voice — I completely missed the meaning of the whole thing until after the TMS, and then I saw the whole thing clearly. This is what life could be like! I could actually understand conversation. I could understand people, rather than being completely oblivious to all the social signals that are flying around. Wouldn't that be nice?"

Once again, less than an hour after the magnet stopped, Kim's ability to see subtle emotions evaporated. It was gone. And realistically, in all probability, Kim will never get to live a life where she is able to see the social signals that swirl around her.

Which raises this question: Is it really good to get a window into a world you can never actually inhabit?

On this point Kim is clear: "It would be worth seeing it for one minute. It would be worth seeing one interaction. That's how big it was. Because you see the way the world works. You see the way people interact, you understand all the subtleties of conversation that happen on a day-to-day basis, and it's like, 'Wow, that's amazing!' "

I think what happened with Kim was that seeing this other world gave her self-understanding, and the grace that comes with self-understanding. Suddenly, she saw more clearly what she was, and what she wasn't. And that really helped her.

But Kim is a person who relentlessly works on herself. She does meditation and therapy and is constantly searching for the best way to be, so it's not surprising that, for her, this experience bent in a positive direction. She's the kind of person who always finds a silver lining.

But not everyone would experience what happened that way. Kim agrees.

"It could be that you would get a glimpse of this and you couldn't have it, and it would be completely heartbreaking," she says, "and you couldn't get over it. But that's not what happened to me. It could happen. I'm not saying it couldn't. But that's not what happened to me."

Where the research stands now

The brevity of the effect Kim experienced isn't the only aspect that concerns Oberman and other researchers about using TMS as a treatment for autism right now. Kim might be an outlier — she's one of only a handful of people on the autism spectrum who have reported responding to TMS this way.

Though another participant in the study, John Elder Robison, recently published a book about his own dramatic experience with TMS, there is at this point no predicting from the evidence who might be affected this way or why.

Oberman says that in the second study that Kim took part in — the one with the videos — so few participants had reactions similar to Kim's that it didn't amount to a statistically significant finding, and the researchers didn't publish it.

Peter Enticott, another neuroscientist studying autism at Deakin University in Australia, says, "I've done TMS in hundreds of people with autism spectrum disorders, [and] I've never seen pronounced, acute effects like Kim's." Enticott says he has seen modest improvements in other physical symptoms, such as hand waving, in some of the people he has studied. But many people in the experiments — perhaps most — experience no effects at all.

Even when it comes to treating treatment-resistant depression — a use approved by the FDA — researchers still aren't sure why TMS works. And they certainly don't yet know why it might help with autism.

Though the procedure is painless, and seems mostly benign, there are already certain known risks: People who have epilepsy, for example, have a slightly increased risk of seizure during TMS.

At this point, none of the studies using TMS on people with autism have included more than a couple of dozen participants. It's quite possible that what look like promising results in some of these little studies would disappear in larger clinical trials, Oberman and Enticott agree.

Even the experimental work is "at its very early stages," Enticott says. "With that comes managing people's expectations, and not providing unrealistic or false hope." Every brain and every case of autism is different.

"Maybe we're on to something," Oberman says, but the next questions are already pressing: "Why, and how do we make it for everybody? I don't know yet."

Oberman is planning more studies. She would like to use the technique in conjunction with MRI, to try to understand more about the workings of each individual's brain before trying TMS as a treatment.

"We're doing smarter studies," Oberman says, but even some fundamental questions "are not going to be answered overnight, or simply."

Kim's conclusions

As for Kim, she says the pain and self-doubt she felt right after the first experiment have receded, and she now feels more at ease than she did before she glimpsed emotion. She not only understands herself better, she says, but also sees the world differently than she did before participating in the experiments: Maybe partly because it's more understandable, it seems a kinder place.

She says she still thinks a lot about one of the videos she was shown during the second experiment. In the video two employees were saying mean things to a fellow employee named Frank. Kim says the first time she watched it — before the TMS — she couldn't answer any of the questions the researchers asked her about it. Afterward though, she understood not only the video, but also, one of the big mysteries that has dominated much of her life.

"It never made any sense to me as to why people would be mean to somebody else. Why would you be mean to somebody?" she asks.

"And what I saw, is that when the two employees were there and talking together, and then were giving Frank a hard time, the primary thing was not that they were trying to be mean to Frank," Kim says. "The primary thing was that they were bonding. Those two people were actually building a bond between the two of them."

Their means of doing that, she now realizes, "was to be nasty to Frank."

It made her think back to her own childhood. "Oh! Maybe that's what these kids were doing when they were bullying me. The primary thing was that they were bonding. The secondary thing was that I was being bullied."

It's much easier to live in a world that makes sense and follows a sensible logic — where people are mean, not just for fun, but because they want to belong and feel safe. That's the world Kim lives in now.

But the point of this story is not that Kim "can't see" and we can. The truth is we can't see what we can't see either. As Kim said, we believe our senses, but our senses often lie. Or, maybe, not lie exactly — it's just that, like Kim, we have things outside the focus of our attention, and so we often live out our lives inside frames we don't realize we have.

The nice thing about a frame of reference is that if you can just figure out which one you're using, you can work to shift it. That's what happened to Kim. When she was 54 years old, a couple of researchers pressed a magnet to her head, shot a magnetic field through her skull, and now Kim knows a lot more about the life she's living.

Angus Chen contributed additional reporting to this story.

Copyright 2016 NPR. To see more, visit NPR.
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'Unbroken Brain' Explains Why 'Tough' Treatment Doesn't Help Drug Addicts

NPR Health Blog - Thu, 07/07/2016 - 2:21pm
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July 7, 20162:21 PM ET Heard on Fresh Air

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Tough love, interventions and 12-step programs are some of the most common methods of treating drug addiction, but journalist Maia Szalavitz says they're often counterproductive.

"We have this idea that if we are just cruel enough and mean enough and tough enough to people with addiction, that they will suddenly wake up and stop, and that is not the case," she tells Fresh Air's Terry Gross.

Szalavitz is the author of Unbroken Brain, a book that challenges traditional notions of addiction and treatment. Her work is based on research and experience; she was addicted to cocaine and heroin from the age of 17 until she was 23.

Szalavitz is a proponent of "harm reduction" programs that take a nonpunitive approach to helping addicts and "treat people with addiction like human beings." In her own case, she says that getting "some kind of hope that I could change" enabled her to get the help she needed.

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On her criticism of 12-step programs

I think that 12-step programs are fabulous self help. I think they can be absolutely wonderful as support groups. My issue with 12-step programs is that 80 percent of addiction treatment in this country consists primarily of indoctrinating people into 12-step programs, and no other medical care in the United States is like that. The data shows that cognitive behavioral therapy and motivational enhancement therapy are equally effective, and they have none of the issues around surrendering to a higher power, or prayer or confession.

I think that one of the problems with the primary 12-step approach that we've seen in addiction treatment is that because the 12 steps involve moral issues, it makes people think that addiction is a sin and not a disease. The only treatment in medicine that involves prayer, restitution and confession is for addiction. That fact makes people think that addiction is a sin, rather than a medical problem. I think that if we want to destigmatize addiction, we need to get the 12 steps out of professional treatment and put them where they belong — as self-help.

On the efficacy of maintenance treatment

Buprenorphine and methadone are the two most effective treatments that we have for opioid addiction, and that is when they are taken indefinitely and possibly for a lifetime. So these medications are opioids themselves. They each have slightly different properties ... but what they do is they allow you to function completely normally. You can drive. You can love. You can work. You can do everything that anybody else does. ...

The way they are able to do that is because if you take an opioid in a regular steady dose every day at the same time and the dose is adjusted right for you, you will not experience any intoxication. The way people with addiction experience intoxication is that they take more and more and more, they take it irregularly, the dosing pattern is completely different. But if you do take it in a steady-state way — which is what happens when you are given it at a clinic every day at the same time — you then have a tolerance to opioids which will protect you if you relapse, and will mean that the death rate from overdose in people who are in maintenance is 50 to 70 percent lower than the death rate for people who are using other methods of treatment, and that includes all of the abstinence treatments.

Additional Information: Related NPR Stories Shots - Health News Does Addiction Treatment Require A Higher Power? 13.7: Cosmos And Culture 'Unbroken Brain' Offers New Insights On Addiction

So maintenance is a really important treatment option for people with opioid addiction. It should be the standard of care. No one should ever be denied access to it. Unfortunately, we have this idea that if you take methadone or buprenorphine, you are just substituting one addiction for another.

On using harm reduction instead of tough love to help addicts

We do know from looking at the data that if you are kind and supportive and empathetic — if you do things like provide clean needles, provide opportunities for people to reverse overdose, provide safe injecting spaces — those things do not prolong addiction. And if tough love was the answer, and the idea was you shouldn't enable addiction, if that theory was correct, those things should all prolong addiction, and the exact opposite is true. When you go into a needle exchange, one of the most amazing things is people are just treated with dignity and respect. And when you're an active drug user, when you are injecting, everybody crosses the street to avoid you. And here you're just seen as a person who deserves to live, and you deserve a chance. And it's that that gives people hope. And it's that that shortens the period of addiction.

Maia Szalavitz is a journalist who has been covering addiction and drug related issues for nearly 30 years. She writes a column for Vice and has been a health reporter and columnist for Time magazine.

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On not serving any time in prison after being caught with 2.5 kilos of cocaine when she was 20 years old

I have to say that being white and being female and being a person who was at an Ivy League school and being privileged in many other ways had an enormous amount to do with ... why I was not incarcerated and why I'm not in prison now. I think our laws are completely and utterly racist. They were founded in racism, and they are enforced in a thoroughly biased manner. I was extraordinarily lucky to have an attorney and a judge that saw that I was getting better, and that allowed me to avoid that.

Copyright 2016 Fresh Air. To see more, visit Fresh Air.
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Synthetic Stingray May Lead To A Better Artificial Heart

NPR Health Blog - Thu, 07/07/2016 - 2:02pm
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July 7, 20162:02 PM ET Heard on All Things Considered

(Left) The tissue-engineered robotic ray, made of gold, silicone and live muscle cells. (Right) The titanium molds that scientists used to create the rays.

Karaghen Hudson and Michael Rosnach

Scientists have created a synthetic stingray that's propelled by living muscle cells and controlled by light, a team reports Thursday in the journal Science.

And it should be possible to build an artificial heart using some of the same techniques, the researchers say.

"I want to build an artificial heart, but you're not going to go from zero to a whole heart overnight," says Kit Parker, a bioengineer and physicist at Harvard University's Wyss Institute. "This is a training exercise."

Previous artificial hearts have been versions of mechanical pumps. An artificial heart made from living muscle cells would behave more like a natural heart, Parker says, and would be able to grow and change over time.

"The heart's built the way it is for a reason," he says. "And we're trying to replicate as much of that function as we possibly can."

A heart and a stingray may seem pretty different. But both need to overcome problems that involve fluid and motion, Parker explains. A stingray has to propel itself through the water. A heart has to propel blood through the circulatory system.

And all of that was on Parker's mind a couple of years ago when he visited an aquarium with his daughter. At an exhibit where visitors can touch rays as they swim by, his daughter put her hand in the water. "The stingray was coming at it," he says, "and with a quick flick of its pectoral fin it just smoothly evaded her hand."

The coin-sized synthetic stingray (left) next to a skate that nature made, Luecoraja erinacea.

Karaghen Hudson/Science

Parker realized that this sort of split-second adjustment is something the heart does all the time as it senses changes in blood flow or pressure.

"The idea just hit me like a thunderbolt," he says.

By building an artificial stingray, Parker figured, he could learn how to replicate the animal's ability to respond instantly to changing conditions.

So he came up with a strategy and presented it to Sung-Jin Park, a researcher in his lab.

"I sat down with him," Parker says, "and I said, 'Sung-Jin, we're going to take a rat apart; we're going to rebuild it as a stingray; and then we're going to use a light to guide it.' And the look on his face was both sorrow and horror."

Parker's lab had previously built an artificial jellyfish. But a ray was much more complicated. And the team was facing tough questions like, how do you to take cells from a rat and make them swim like a fish?

Park and the rest of the team started working, though. And, eventually, they succeeded.

Their synthetic ray, which is about the size of a nickel, has a transparent body made of silicone and a rudimentary skeleton made of gold.

The ray is propelled by 200,000 heart muscle cells taken from a rat. The cells have been genetically altered to allow the hybrid creature to follow a pair of blue lights.

"We can guide this thing around," Parker says. "It swims through obstacle courses."

Stingray Swimming

The ray has been engineered to move in response to pulses of light.

Credit: Sung-Jin Park and Kyung Soo Park/Science

And the creature displays the rhythmic, undulating motion of a real stingray. Replicating that motion is one of the project's key accomplishments, says John Dabiri, a professor of engineering at Stanford who worked with Parker on the artificial jellyfish.

To get the ray's tail to undulate, the team had to come up with a way to trigger muscle cells in sequence. The effect is similar to when the crowd at a ballgame does the wave, Dabiri says.

"You have one group standing up and then the next and then the next. Well, in the case of the muscle here, they're doing the same thing," he says. "They're able to get a certain section of muscle to contract and then the next and then the next."

That coordinated movement is necessary for many biological functions, like swallowing. It's also the way the heart beats, with areas contracting in a precise sequence.

Another advance is the ability to activate muscle cells with light rather than electricity, Dabiri says. That allows scientists to control precisely which part of a muscle contracts. So light could act as a sort of pacemaker in an artificial heart that's made this way.

The artificial stingray is likely to make some people uncomfortable, Dabiri says, because it raises questions about when a machine becomes a living organism.

In this case, the artificial ray pretty clearly isn't an organism, he says. It can't grow, adapt or reproduce. But scientists should be considering the possibilities as they pursue other projects like this, he says.

"We want to make sure we think about the ethical issues hand in hand with just asking what we can do," Dabiri says.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

It's Tough To Make Good Health Choices, But Science Can Help

NPR Health Blog - Thu, 07/07/2016 - 11:41am

If you're having trouble seeing the right side of this plate, you're still an OK person. Really.

Jamie Jones/Ikon Images/Getty Images

The year is half over. So I took a moment over the long holiday weekend to triumphantly write, "Mission accomplished!" in ink next to each of my New Year's resolutions.

Just kidding. I didn't actually continue much past January 15 with my vows to run four days a week and ditch all desserts from Monday through Friday. And I am certainly not alone. Simply wanting to change certain behaviors that we know raise the risk for health problems isn't enough to get most of us to follow through, says John Updegraff, a professor of psychology at Kent State University.

Research suggests, however, that some techniques can raise the odds, at least a bit, of making positive behavior changes. Here are some strategies:

Remind yourself that you're OK.

It's easy to sink into a pit of self-loathing when faced with the fact that you don't eat any vegetables unless they're fried. We all want to feel good about ourselves. So when we read health-risk information that makes us feel like we've made bad decisions, we may tune out rather than work to change our behavior, explains Tracy Epton, a research associate at the University of Manchester, in an email.

Simply reminding yourself that you're an OK person may increase your readiness to change. In a review published in 2014, Epton and colleagues analyzed existing research and found self-affirmation techniques combined with persuasive health information can help people decide to change — and then actually do it. (The effects were small, the authors of the analysis wrote, but comparable to similar analyses of other behavior-changing efforts.)

You don't have to look in the mirror and pump yourself up by saying "I'm the greatest of all time." It's as simple as reminding yourself of your values, character strengths and things that you're proud of. "That takes the focus off that health behavior being their defining, negative feature," says Updegraff.

Give yourself an incentive to change.

Financial incentives have been shown to aid a range of behavior changes including smoking cessation and getting kids to eat more fruits and veggies. That's why many workplaces offer incentives – such as cash, insurance premium reductions or deposits to a health savings account — for taking part in physical activity challenges or other wellness efforts.

The Salt Place A Bet On Your Weight-Loss Goal, And You May Win Twice

You can engineer incentives for yourself, using your own money, says Kevin Volpp, a physician and director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania. Companies such as StickK and HealthyWage let people essentially bet on their ability to meet their goals. StickK uses "commitment contracts" that specify that you'll pay a certain person or group (such as a charity you disagree with) if you don't meet your goals. With HealthyWage, which is specifically for weight loss, you set a goal and a time frame, and put up some cash. If you meet the goal, the company pays you a financial prize. If you fail, you forfeit your upfront payment. In contrast to workplace reward programs, this method plays to our human tendency to suffer losses more acutely than we value gains.

Be specific about your plans.

Merely stating good intentions isn't likely going to make you change your ways.

Some research suggests that being much more specific — naming the where, when and how — can help turn intentions into action. So instead of, "I want to run more," I could say, "I'm going to get home from daycare drop-off, put my shoes on, and head out the door for at least 30 minutes from Tuesday through Friday, rain or shine." These so-called implementation intentions seem to help increase physical activity as well as help increase healthy food behaviors.

Combine your "wants" and your "shoulds."

One technique to do the things we aren't so crazy about is to pair them with the things we love. It's called "temptation bundling," a concept described by the University of Pennsylvania's Katherine Milkman. Pick something you enjoy doing and allow yourself to do it only when you're exercising or working on some other good habit. There's some early evidence that this technique might help: A 2014 study that Milkman led found that people who were allowed gym-only access to iPods loaded with audiobooks they wanted to hear increased their gym attendance. (Volpp was also one of the authors of this study.)

The effects of the temptation bundle waned over time, the study found, but in my own one-person experiment of more than a year, I've found I can persist with the habit if the "wants" are fresh and consistently appealing. So I allow myself to listen to the endless flow of new episodes of my favorite podcasts, but only when I'm walking or doing active housework.

Engineer your environment.

In the words of the great philosopher Mike Tyson, "Everyone has a plan until they get punched in the mouth." Or tempted by a plate of doughnuts. Focusing on your own actions can help, but you can also look around at your environment to see how it's supporting or undermining your health goals.

Fitness & Nutrition Trying To Lose Weight? Your Environment, Mindset May Need Work First

The Food & Brand Lab at Cornell University has studied a host of things that influence what and how much we eat. Among its findings: Cluttered kitchens encourage overeating. Dining with someone who is overweight may make us eat more. Marketing fruit and veggies to kids with colorful banners and cartoons can boost intake. Dimly lit restaurants are associated with less healthful meal choices.

Take a look at the research and see what you can apply to your own home or workplace.

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She's on Twitter: @katherinehobson.

Copyright 2016 NPR. To see more, visit NPR.
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What Did Nearsighted Humans Do Before Glasses?

NPR Health Blog - Thu, 07/07/2016 - 10:22am
  • Hide caption Spectacles with leather frame, circa 1700. Previous Next Courtesy of the American Academy of Ophthalmology Museum of Vision
  • Hide caption Nuremberg magnifier and wooden case. German, circa 1700. Before spectacles become easier to wear and more comfortable, hand-held models were more common than those for the face. Previous Next Courtesy of the American Academy of Ophthalmology Museum of Vision
  • Hide caption Wig spectacles with tortoiseshell frame. English, circa 1810. To fit around the wigs popular at the time, early temple pieces wrapped around the back of the head Previous Next Courtesy of the American Academy of Ophthalmology Museum of Vision
  • Hide caption Spectacles with copper frame, circa 1600-1800. Jenny Benjamin of the American Academy of Ophthalmology's Museum of Vision says a lack of innovation in frames over certain time periods can make dating spectacles quite difficult. Previous Next Courtesy of the American Academy of Ophthalmology Museum of Vision
  • Hide caption Folding lorgnette with blue and white enamel, rose-cut diamonds and centrol Limoges plaque depicting bathers and cherubs. French, circa 1800. Though glasses were frequently associated with age or infirmity, the wealthy did what they could to dress glasses up. Previous Next Courtesy of the American Academy of Ophthalmology Museum of Vision

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Nearsightedness, or myopia, is increasing at an eye-popping rate. By 2050, scientists predict more than 4.7 billion people, roughly half of the global population, will be nearsighted.

Fortunately, humans have created a solution — eyeglasses! People can rest assured they will always be able to read the dumb bumper stickers on the cars in front of them. But how did people manage thousands of years ago?

Shots called ophthalmologists and corrective eyewear historians (yes, they exist) to find answers.

First, the prevalence of human eyesight issues has changed over time. "As long as primates have been around, there's probably been myopia," says Dr. Ivan Schwab, a professor of ophthalmology at the University of California, Davis and author of Evolution's Witness: How Eyes Evolved. But he says the rates of myopia have skyrocketed over the past three centuries.

The reason likely has to do with a rise in reading, Schwab says. Though genes and nutrition may play a role in nearsightedness, he says education and myopia seem to be linked, suggesting that when people do a lot of close work, their eyes grow longer — the better to focus up close, but the worse for long-distance vision. Some ophthalmologists believe that dim light exacerbates this effect, Schwab says.

Scientists are still working out the exact mix of factors that contribute to myopia, but, on average, humans thousands of years ago probably had to squint less to see at a distance, according to Schwab. What happened to the few who were shortsighted?

"You can imagine that if people with nearsightedness had some special skill, they might even be revered," says Schwab. Fine engravings found on ancient coins, for example, might have benefited from a nearsighted artist's craftsmanship. "Now that's just speculation," he adds. "I can't prove that." Another possible upside of myopia? It could mitigate the difficulty of seeing up close that comes with aging.

Things started to look up for the visually challenged at the end of the 13th century, when the earliest known eyeglasses were invented in northern Italy. The region was a hub for glass production, says Neil Handley, the museum curator at the College of Optometrists, London. Merchants soon carried spectacles along the Silk Road to Asia, where they served as status symbols. Some judiciary committees in China even mandated spectacles as part of the uniform. Still, they didn't become as common there as they did in Europe, where spectacles were produced.

These glasses had more in common with magnifying glasses than today's eye accessories. "You pick them up, and you feel the difference," says Jenny Benjamin, director of the American Academy of Ophthalmology's Museum of Vision. "You can't wear them on your face; they'd just fall off."

Early glasses were heavy and prone to shattering, Benjamin says. They were intended to help people read, rather than aid nearsightedness. Often, glasses featured quartz instead of glass, since the latter was often turbid.

Glasses for nearsightedness likely arose in the 15th century. "Because they were seen as being unusual and rare, they were seen as having magical powers," says Handley. People who wore glasses "were in league with the devil, immoral."

But after the Reformation, when literacy rates climbed, spectacles became more common. In the 1700s, temple pieces — the long extensions of glasses that fit snugly against the head — allowed people to wear glasses throughout the day. Styles diversified rapidly, featuring different colors and expensive materials.

"They're still universally seen as a disability aid. And they're slightly embarrassing," Handley says of glasses in the 18th century. "But nonetheless, if you're at the richer end of the market, you can show off a bit."

Before prescriptions, customers tried on glasses and chose a pair through trial and error, often from a traveling peddler. But in the 1800s, Handley says, people began receiving eye exams for glasses. In 1862, Dutch ophthalmologist Herman Snellen invented the standardized eye chart that taunts so many today.

Of course, glasses still present challenges. Xavier Holland of Boston, 28, has worn glasses for nearsightedness since he was 10. The glasses fog when Holland opens the dishwasher and make 3-D glasses at the movies a pain.

But Holland appreciates another benefit ancient humans didn't get to enjoy: fashion. "It's an easy way to seem interesting or different," he says. "If you're looking for a way to jazz up your look, you can always just get some new frames."

Copyright 2016 NPR. To see more, visit NPR.
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After Medical Marijuana Legalized, Medicare Prescriptions Drop For Many Drugs

NPR Health Blog - Wed, 07/06/2016 - 5:09pm

In states that made medical marijuana legal, prescriptions for a range of drugs covered by Medicare dropped.

Chris Hondros/Getty Images

Prescription drug prices continue to climb, putting the pinch on consumers. Some older Americans appear to be seeking an alternative to mainstream medicines that has become easier to get legally in many parts of the country.

Research published Wednesday found that states that legalized medical marijuana — which is sometimes recommended for symptoms like chronic pain, anxiety or depression — saw declines in the number of Medicare prescriptions for drugs used to treat those conditions and a dip in spending by Medicare Part D, which covers the cost on prescription medications.

Because the prescriptions for drugs like opioid painkillers and antidepressants — and associated Medicare spending on those drugs — fell in states where marijuana could feasibly be used as a replacement, the researchers said it appears likely legalization led to a drop in prescriptions. That point, they said, is strengthened because prescriptions didn't drop for medicines such as blood-thinners, for which marijuana isn't an alternative.

The study, which appears in Health Affairs, examined data from Medicare Part D from 2010 to 2013. It is the first study to examine whether legalization of marijuana changes doctors' clinical practice and whether it could curb public health costs.

The findings add context to the debate as more lawmakers express interest in medical marijuana. This year, Ohio and Pennsylvania passed laws allowing the drug for therapeutic purposes, making it legal in 25 states, plus Washington, D.C. The approach could also come to a vote in Florida and Missouri this November. A federal agency is considering reclassifying medical marijuana under national drug policy to make it more readily available.

Medical marijuana saved Medicare about $165 million in 2013, the researchers concluded. They estimated that, if medical marijuana were available nationwide, Medicare Part D spending would have declined in the same year by about $470 million. That's about half a percent of the program's total expenditures.

That is an admittedly small proportion of the multibillion-dollar program. But the figure is nothing to sneeze at, said W. David Bradford, a professor of public policy at the University of Georgia and one of the study's authors.

"We wouldn't say that saving money is the reason to adopt this. But it should be part of the discussion," he added. "We think it's pretty good indirect evidence that people are using this as medication."

The researchers found that in states with medical marijuana laws on the books, the number of prescriptions dropped for drugs to treat anxiety, depression, nausea, pain, psychosis, seizures, sleep disorders and spasticity. Those are all conditions for which marijuana is sometimes recommended.

The study's authors are separately investigating the effect medical marijuana could have on prescriptions covered by Medicaid, the federal-state health insurance program for low-income people. Though this research is still being finalized, they found a greater drop in prescription drug payments there, Bradford said.

If the trend bears out, it could have other public health ramifications. In states that legalized medical uses of marijuana, painkiller prescriptions dropped — on average, the study found, by about 1,800 daily doses filled each year per doctor. That tracks with other research on the subject.

Marijuana is unlike other drugs, such as opioids, overdoses of which can be fatal, said Deepak D'Souza, a professor of psychiatry at Yale School of Medicine, who has researched marijuana. "That doesn't happen with marijuana," he added. "But there are whole other side effects and safety issues we need to be aware of."

Study author Bradford agreed: "Just because it's not as dangerous as some other dangerous things, it doesn't mean you want to necessarily promote it. There's a lot of unanswered questions."

Because the federal government classifies marijuana as a Schedule I drug, doctors can't technically prescribe it. In states that have legalized medical marijuana, they can only write patients a note sending them to a dispensary.

Insurance plans don't cover it, so patients using marijuana pay out of pocket. Prices vary based on location, but a patient's recommended regimen can cost as much as $400 per month. The Drug Enforcement Agency is considering changing that classification — a decision is expected sometime this summer. If the DEA made marijuana a Schedule II drug, the move would put it in the company of drugs such as morphine and oxycodone, making it easier for doctors to prescribe and more likely that insurance would cover it.

To some, the idea that medical marijuana triggers cost savings is hollow. Instead, they say it is cost shifting. "Even if Medicare may be saving money, medical marijuana doesn't come for free," D'Souza said. "I have some trouble with the idea that this is a source of savings."

Still, Bradford maintains that if medical marijuana became a regular part of patient care nationally, the cost curve would bend because marijuana is cheaper than other drugs.

Lester Grinspoon, an associate professor emeritus of psychiatry at Harvard Medical School, who has written two books on the subject, echoed that possibility. Unlike with many drugs, he argued, "There's a limit to how high a price cannabis can be sold at as a medicine." He isn't associated with the study.

And, in the midst of the debate about its economics, medical marijuana still sometimes triggers questions within the practice of medicine.

"As physicians, we are used to prescribing a dose. We don't have good information about what is a good dose for the treatment for, say, pain," D'Souza said. "Do you say, 'Take two hits and call me in the morning?' I have no idea."

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

How Parents Can Help Their Underage Kids Resist Alcohol

NPR Health Blog - Wed, 07/06/2016 - 11:52am

"Honey, I think we need to talk about drinking."

Imagezoo/Getty Images

While a sense of inevitability often surrounds the topic of teen drinking, adults can play an important role in preventing underage alcohol use.

Two recent studies provide guidance for parents. One finds that parents who set limits in a warm and supportive environment reduced the risk that their adolescent children would binge drink. The other study reports on the potential of a home-based program that educates parents and children about alcohol prevention.

The stakes are high. About 1 in 6 teens drank alcohol before turning 13, and about the same proportion of high school kids has binged on alcohol, according to the latest biannual Youth Risk Behavior Survey by the Centers for Disease Control and Prevention. Overall, a third of teenagers drink — down from about half of teens 25 years ago, but still a problem.

"Although it is common for adolescents and young adults to try psychoactive substances, it is important that this experimentation not be condoned, facilitated, or trivialized by adults," notes the introduction to an updated screening protocol by the American Academy of Pediatrics. The group encourages doctors to ask adolescents about drug and alcohol use during routine visits.

At home, how Mom and Dad manage their roles — and the signals they send about alcohol use — affect their children's future drinking behavior. Parenting style, drinking frequency, and expectations influence whether adolescents will binge drink, according to results of a study published in the July issue of Prevention Science. In the same issue, another study finds that a home-based prevention program used by parents with their elementary school-age children made the kids less inclined to drink four years after the start of the program.

When adolescents drink, they tend to do so excessively, making the most of their limited access to alcohol. Binge drinking — consuming four, for females, or five, for males, drinks at a time — puts the imbiber at risk of fatal accidents, injuries, violence and legal problems. Social psychologist William D. Crano at Claremont Graduate University in Claremont, Calif., and his colleagues wondered whether certain conditions in adolescence "had any predictive power for what's going to happen" in terms of alcohol use and incarceration.

The researchers looked at data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), which has interviewed a nationally representative group four times, beginning in the 1994-1995 school year, when the participants were in seventh through 12th grades. The most recent survey occurred in 2008, when the respondents had reached ages ranging from 24 to 32. Parent interviews occurred in the first year of the project.

Crano and his group focused on four factors from the first wave of interviews:

  • whether parents monitored their teens,
  • the warmth parents expressed to their teens,
  • how frequently parents drank,
  • whether parents thought their kids were drinking.

The study involved more than 9,400 adolescents and their parents. Teens answered questions about parental monitoring and warmth; parents responded to queries about their drinking and expectations. In later surveys, the Add Health project collected data on teen and young adult binge drinking and incarceration rates.

Adolescents whose parents neither kept an eye on them nor provided a supportive home environment were more likely to binge drink. These parental behaviors, along with underage drinking, predicted binge drinking as young adults. Furthermore, those who binged as teens and young adults were more likely to be arrested.

The study suggests that parents do make a difference. "Parental monitoring and warmth are a protective device against kids' binge drinking," says Crano. But the two need to go hand in hand. "If you have surveillance without warmth, you've got a problem," he adds. "You want the relationship between a parent and a child to be close enough and warm enough that the child discloses behaviors and what they are thinking, and the parent can offer advice" that reinforces rules but doesn't disparage the child.

The study also found that how often parents drank was predictive of teen and young adult binge drinking. While the survey didn't ask about the amount of alcohol consumed, the research supports the idea that parents' drinking behavior can send a powerful message to kids in terms of what is acceptable.

Finally, it was more likely that adolescents were drinking if their parents expected they were drinking. This self-fulfilling prophecy may stem from parents not intervening and educating their kids when they suspect alcohol use, says Crano, even though that is exactly what is needed.

Crano and his group argue that national prevention campaigns would do well to target parents, not just teens. "Parents are an easier audience," he says. "They are quite open to learning how to do better for their children."

Armed with the right information, parents can direct a prevention campaign in their own living rooms. Social ecologist Christine Jackson at RTI International in Durham, N.C., and colleagues there and at the University of North Carolina, Chapel Hill report on a home-based parenting program meant to counter parents' misconceptions about kids and alcohol, support communication in the family, and encourage parents to set rules regarding alcohol use.

Jackson notes that a child's first taste of alcohol often comes from a drink offered by a parent. Contrary to the belief that sipping will satisfy kids' curiosity about alcohol and deter future drinking, previous work by Jackson and colleagues found that fifth-grade children permitted by parents to try an alcoholic beverage were twice as likely to drink in seventh grade as peers not granted sips.

"In the short term, allowing children to try alcohol simply teaches them that parents don't mind if they have alcohol," Jackson says. "In the long term, allowing children to have alcohol increases their odds of underage drinking during adolescence."

If kids have positive ideas about alcohol — for example, that drinking makes one popular — they are more likely to drink, notes Jackson. The program set out to provide alternative, protective ideas. It helped parents discuss how alcohol is harmful to children's health and commit to keeping kids alcohol-free. It also sought to empower kids to reject social pressures to drink.

To test the approach, the researchers recruited third-grade children and their mothers from school districts in three Southern states, primarily North Carolina. Just over 1,000 children were randomly divided into two groups, one whose families received the five-month-long alcohol prevention program, and one provided with an obesity-prevention program for comparison. The materials included magazines, games and role-playing activities.

Jackson and her colleagues interviewed the kids about their beliefs and attitudes regarding alcohol before the program started. At the same time, they queried mothers about how often both parents drank and about the mother's racial and ethnic identity and education. In the second and third years of the study, families received a one-month booster program. Four years from the start of the program, the researchers asked the kids again about their alcohol-related beliefs and attitudes.

The third-graders who had received the alcohol prevention program were significantly less inclined to drink at the four-year follow-up, when they were in seventh grade, than those in the obesity program. This was true regardless of their parents' drinking habits or mother's education, race or ethnicity. "This means that the program has a sustained effect on children's attitudes and intentions about alcohol use," says Jackson.

Kids develop ideas about alcohol with or without their parents' direct input. "Encourage conversation with kids about issues that are important to them," says Crano. "You want to be the person to help them."

Aimee Cunningham is a freelance science journalist based in the Washington, D.C., area.

Copyright 2016 NPR. To see more, visit NPR.
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Obama Administration Eases Restrictions On Doctors Who Treat Opioid Addiction

NPR Health Blog - Wed, 07/06/2016 - 9:09am

As many as 70,000 more people could get access to office-based treatment for opioid use now that the administration has raised the cap on the number of patients each doctor is allowed to treat.

Jamie Grill/Getty Images

The Obama administration is making it easier for people addicted to opioids to get treatment.

Health and Human Services Secretary Sylvia Burwell announced new rules Wednesday to loosen restrictions on doctors who treat people addicted to heroin and opioid painkillers with the medication buprenorphine.

Doctors who are licensed to prescribe the drug, which is sold mostly under the brand name Suboxone, will be allowed to treat as many as 275 patients a year. That's almost triple the current limit of 100, and HHS estimated that as many as 70,000 more people may have access to the drug as a result.

"There are a number of ways we are trying to increase access to medication-assisted treatment," said Michael Botticelli, the director of national drug control policy, on a conference call with reporters. "This rule itself expands access and gets more physicians to reach more patients."

Suboxone is itself an opioid. It eases withdrawal symptoms and cravings, but doesn't make people high.

In 2000, Congress passed legislation that allows doctors who are trained and pass a test to offer office-based buprenorphine treatment. However, the same law capped how many patients a doctor can treat. These are the only medications that are under such restrictions.

In a related move, HHS said it is changing how it uses patient satisfaction surveys to determine Medicare payments. Burwell said some doctors and hospitals said they felt pressure to prescribe opioid painkillers because the surveys could affect their income.

"This rule eliminates the connection between pain management questions in the survey and payments to doctors and to hospitals," she said on the conference call.

Even as they announced the new rules, administration officials urged Congress to allocate more money to help pay for more addiction treatment programs.
House and Senate negotiators are considering a series of opioid treatment bills, but those proposals don't include all the funding President Obama requested.

Botticelli said many Democrats in the House have said they won't sign off on a compromise bill unless it includes the $1.1 billion that the president requested.

Botticelli said an average 129 people a day die from opioid overdoses.

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What Puts The Waddle In The Walk Of Moms-To-Be?

NPR Health Blog - Tue, 07/05/2016 - 3:18pm

Waddle, don't run.

Compassionate Eye Foundation/Natasha Alipour Faridani/Getty Images

I was never good at strolling.

If I had a destination, I walked quickly. Not because I wanted exercise, mind you, but because it felt natural.

That all changed with my first pregnancy. The nonpregnant me bolted across a street with five seconds left on the crossing signal. The uber-pregnant me much preferred a full 30-second allotment. Anything less and I waited for the next traffic cycle.

This change of pace was entirely out of my control. As I neared my due date, my once-brisk stride was shorter, my stance wider, my torso tilted farther backward.

I had morphed into a waddler! And I could only waddle so fast.

Now, at 28-weeks pregnant with my second child, I'm beginning to waddle again. I'm thrilled to be expecting, but I'm already missing my normal speed.

Obstetricians tell us that there's a good explanation for why pregnancy changes our gaits.

"There are a lot of joints in the pelvis. Those are going to loosen as the pregnancy goes on, which is probably how the body adapts to allow a fairly good-sized baby to fit through," explains Dr. Daniela Carusi, director of both general gynecology and surgical obstetrics at Brigham and Women's Hospital in Boston. The loosening of the joints and the downward pressure from the growing belly actually cause the pelvis to get wider, she says. A wider pelvis means a wider stance.

That explains part of the waddle. The other part, according to Carusi, is caused by a shift in our center of balance. "As the belly gets bigger, which is the spot in the body which marks the center point, the weight moves forward and that makes the spine curve more inward," she says.

We pregnant women can't help but lean back.

I wondered what would happen if I attempted to trade comfort for more graceful motion, if it was even possible to force myself to return to something closer to my former stride.

Carusi warns that it wouldn't work. "You could reposition your legs, but it's hard to make your hips narrower," she says. "What you'd be doing is compensating for the change instead of overriding it."

"I don't think it makes sense to narrow the gait," agrees Stephanie Prendergast, a physical therapist at The Pelvic Health and Rehabilitation Center in Los Angeles. "Keeping the gait wider is safer for balance reasons."

Prendergast says we could consider making slight adjustments to the way we stand. "When they're standing still, many pregnant women will push their bellies out and lean backward," she explains. "But then your ligaments at the front of the hip are holding up your weight." If we don't lean back so far, she says, our gluteal muscles could take some of the weight and our hips would hurt less.

I tried to adjust my stride anyway, of course. Unsurprisingly, it felt terrible. When I straightened my back, my shoulders arched forward. When I narrowed my stance, my balance was all off. Other women have had similar experiences.

"I tried to walk with my feet closer together, but after a while that hurt more than changing my gait," says mother-to-be Keke Gibb, a science professor at Baker University in Baldwin City, Kan., who spoke with me on her due date. "It's most comfortable if you widen your stance a lot," she explains. "It feels like my thighs hate each other. I try not to let them touch while I do a really awkward sashay through the neighborhood. I use my whole body to swing one leg forward at a time."

There is no fighting the pregnant waddle.

I take some comfort in knowing that there's a small community of scientists investigating how this altered motion affects our lives. These researchers attach reflective stickers to a pregnant woman's body and then use special cameras to capture the 3-D movement of the stickers as she walks, stands up, or does other simple tasks that can become challenging late in pregnancy.

"When we look in our software, the women look like stick figures moving in 3-D, so we can capture different aspects of how they move, rotate, flex and extend," says Jean McCrory, a biomechanist at West Virginia University who studies gait and balance in pregnant women.

McCrory documented, for example, how pregnant women walk with pelvises tilted backward and feet spread wider apart. Others have shown how we rise from chairs more slowly, and with a greater attention to balance.

In a recent study, scientists at Hiroshima University studied the mechanics of movement as pregnant and nonpregnant women rose from a chair, picked up two stacked plates, turned to the right, and then walked away. The researchers showed that pregnant women flex their hips less while walking and lean back more while standing.

These findings will come as no surprise to obstetricians or anyone who has ever had a baby bump of her own. But studies like these might one day help scientists figure out how to make everyday tasks safer for pregnant women. McCrory, for example, wants to use her knowledge of pregnant motion to find ways to prevent pregnant women from falling — a worthy goal since over a quarter of pregnant women fall at some point.

I joined that statistic during my last pregnancy when I got overexcited about an old friend visiting. As she got out of her car, I momentarily forgot to waddle and leaped forward to hug her. My toe caught the sidewalk and I fell so slowly and awkwardly that she thought it was intentional — that I was trying to entertain her with some sad attempt at pregnant lady slapstick. The baby and I were fine.

So far I've managed to stay on my feet this pregnancy. For the moment, I also still have some of my prepregnancy speed. I know this because, like so many aspects of pregnancy, people comment on it. Last week, as I strode past two men on my way to work, I overheard one say, "Whoa! Look at how fast she walks — for a pregnant lady."

Copyright 2016 NPR. To see more, visit NPR.
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Young Adults Can Face A Confusing Path To Health Insurance

NPR Health Blog - Tue, 07/05/2016 - 12:04pm

Time to switch from the parents' health plan to something else.

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The Obama administration is making a push to get young adults covered on the health insurance marketplaces, both for their own good and that of the marketplaces. The insurance exchanges need healthy people to balance sicker ones in the risk pool.

Despite beefed-up outreach planned for the coming months, several factors may throw a wrench into enrollment plans for young people.

To start with, the transition from children's Medicaid to adult coverage can be bumpy. Nineteen is the age at which lower-income young adults are generally no longer eligible to be covered as children by the Medicaid or Children's Health Insurance Program. Options for them include moving to adult Medicaid in states that have expanded coverage to 138 percent of the federal poverty level (about $16,000), or buying a subsidized plan on the health insurance marketplace.

"I'm sure there are states that do transitions really well, but I can't point to one," said Shelby Gonzales, a senior health policy analyst who focuses on enrollment and eligibility issues for the Center on Budget and Policy Priorities. "In general, a lot of states are struggling, when [young adults are] being terminated from Medicaid, with getting them on a pathway that's smooth to the marketplace."

The transition to adult Medicaid can also be problematic. Thirty-one states and the District of Columbia have expanded coverage, and it's available for some of these young adults, she said.

Clunky computer systems and uninformative coverage notices may make it easier to drop coverage at age 19 than continue it. Sometimes, for example, a young adult will receive a notice explaining that she's no longer eligible for Medicaid under a particular section of the law, but not receive information about other coverage options.

Or some states don't have a routine process to check whether the 19-year-old is eligible for another category of Medicaid after aging out of child coverage. Or she may get sent to the marketplace for coverage, but wind up filling out all the application information from scratch even though her Medicaid file already has the information.

When young people try to apply for coverage on the marketplace, they may run into another snag: difficulty proving their identity, the first step in the enrollment process. With little or no credit history, they may have to verify their identity by phone or submit documentation that proves they are who they say they are. Such frustrations can lead young people to walk away from the process.

"Any of these are points where you might lose someone," Gonzales said.

Since the health law passed, the uninsurance rate among young people between ages 19 and 25 has fallen by more than 50 percent, according to the Centers For Medicare & Medicaid Services. But young adults are still more likely than other adults to be uninsured.

The Obama administration has acknowledged the difficulty in transitioning young people from Medicaid or their parents' policies to other coverage. It noted that at age 19, the uninsured rate jumped nearly 7 percentage points in 2014, according to the Census data, while 26-year-olds' rate of uninsurance increased 4 percentage points as they aged off their parents' plans.

New restrictions on special enrollment periods may also pose a particular problem for young people, experts say. If people experience certain life events they can qualify for a special enrollment period during the middle of the year to pick a new plan. Insurers complained that people were using a special enrollment period to sign up for coverage to receive medical treatment, then dropping coverage after they got the care they needed. So the Obama administration said that it will begin to require that people document that they really did experience some of the most common life events that have triggered the new enrollment, including marriage, the birth of a child, loss of another type of coverage and a permanent move.

Young people are disproportionately affected by these events. In addition to marriage and childbirth, young adults between the ages of 20 and 29 relocate at twice the rate of older adults, according to Young Invincibles, an advocacy organization for young people.

"I think the new documentation requirements regarding [special enrollment periods] could really backfire, and the result could be different than the administration intends," said Sabrina Corlette, research professor at the Georgetown University Center on Health Insurance Reforms.

One of the challenges of insuring young adults is convincing them that they need it. Many young adults are relatively healthy. When money is tight, health insurance may seem like a luxury they can forgo.

Young Invincibles is trying to get the word out that marketplace coverage can be extremely affordable with premium tax credits and cost-sharing subsidies, said Erin Hemlin, the group's national director of training and consumer education. Young Invincibles also highlights the preventive care benefits that are available in all marketplace plans at no charge to consumers.

Coverage of birth control pills alone may be enough to boost sign-ups. "For young women, they say birth control is the No. 1 selling point," Georgetown's Corlette said.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter:@mandrews110.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Episiotomies Still Common During Childbirth Despite Advice To Do Fewer

NPR Health Blog - Mon, 07/04/2016 - 8:00am

Women go through a lot in the delivery of a healthy baby. But in most cases, doctors say, an episiotomy needn't be part of the experience.

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Episiotomy, a once-routine surgical incision made in a woman's vaginal opening during childbirth to speed the baby's passage, has been officially discouraged for at least a decade by the leading association of obstetrician-gynecologists in the United States.

Nonetheless, despite evidence that the procedure is only rarely necessary, and in some cases leads to serious pain and injuries to the mother, it is still being performed at much higher than recommended rates by certain doctors and in certain hospitals.

In one recent case, Kimberly Turbin, a 29-year-old dental assistant who lives in Stockton, Calif., is suing her former obstetrician for assault and battery after he performed an episiotomy on her in 2013. A video of the birth, with Turbin begging the doctor not to cut her, has been viewed more than 420,000 times.

After the episiotomy, Turbin says, "I had major, major, major, major pain."

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In 2006, the American College of Obstetricians and Gynecologists released a recommendation against the routine use of episiotomy, finding that except in relatively rare cases, the procedure benefited neither mothers nor newborns. In 2008, the National Quality Forum also endorsed limiting the routine use of episiotomies.

Since then, the use of this surgical incision has dropped significantly — from 21 percent of all vaginal births in California in 2005, for example, to fewer than 12 percent in 2014. National trends have been similar.

But that overall drop masks some giant disparities. While the majority of California's hospitals now have episiotomy rates under 10 percent, according to state data, the technique's use at individual hospitals can be five or six times as high.

Dr. Alexander Friedman, an assistant clinical professor of obstetrics and gynecology at Columbia University Medical Center in New York City, who has studied the issue, says sky-high rates at some institutions are surely based on factors that go beyond medical need.

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"If you perform an episiotomy, you're more likely than not going to cause more postpartum pain and discomfort," says Friedman, who was lead author of a 2015 report, published in JAMA, the Journal of the American Medical Association, about the variation in episiotomy rates among hospitals nationally. While the ideal rate of episiotomy is unknown, he says, it should likely be less than 10 percent.

As recently as the late 1970s, episiotomy was used in more than 60 percent of vaginal deliveries across the U.S. because doctors believed a clean incision helped prevent tears between the vagina and rectum, that a clean cut was easier to stitch than a tear, and that the incision prevented overstretching of the muscles surrounding the vagina.

In the past few decades, though, research has shown that the cuts sometimes cause serious pain and injuries, including deep tissue tears, incontinence and sexual dysfunction. The repaired incisions often prove slower to heal than a natural tear.

Armed with this information, many pregnant women started refusing the procedure, and most obstetricians stopped doing it routinely.

But certain doctors are going against that trend.

Dr. Emiliano Chavira, a maternal and fetal medicine specialist at Dignity Health's California Hospital Medical Center in Los Angeles, says he suspects three main reasons why some providers continue to perform routine episiotomies: They've always done them; they lack awareness of best practices; or they want to speed up deliveries.

"Certain segments of the obstetric community are very slow to modernize the practice," Chavira says. "They're very slow to abandon procedures that are not a benefit and, in fact, may be harmful. And it's really disappointing."

There can also be great variation from hospital to nearby hospital, research shows.

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For example, in Los Angeles each of the six hospitals owned by AHMC Healthcare have continued to do episiotomies in more than 29 percent of vaginal births, according to state data. And two of the institutions — Garfield Medical Center in Monterey Park and Whittier Hospital Medical Center in the city of Whittier — have episiotomy rates close to 60 percent. Representatives of the chain and its hospitals didn't return repeated calls and emails requesting comment.

Meanwhile, Kaiser hospitals in Northern California have seen huge reductions in the use of the procedure since the Oakland-based managed care organization undertook an intentional effort to address overuse.

Dr. Tracy Flanagan, director of women's health and maternity at Kaiser Permanente in Northern California, says her office began examining episiotomy rates at different hospitals four or five years ago. They first looked at rates at the hospital level, then at the physician level, she says, and found " a lot of variation."

They first sent the data to the individual hospitals. Then, doctors at each hospital who rarely performed episiotomies were asked to educate their colleagues about the appropriate use and relative risks of the procedure.

Physicians tend to respond best if other physicians present them with a compelling argument to change their ways, Flanagan says. Reliable data, transparency and peer-to-peer education, she adds, is a good recipe for narrowing variation.

The average episiotomy rate for the Northern California Kaiser hospitals is now about 3 percent, Flanagan says.

Zero percent would be too low, she adds; in some cases — if a baby's shoulder is stuck, for instance, or the infant's heart rate drops, or if the mother is exhausted and wants an episiotomy — the procedure's use is warranted.

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Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative and a clinical OB-GYN professor at Stanford University, says the episiotomy data offer a lesson in how quickly practices can change. This evidence also highlights the hospitals where doctors refuse to alter their ways, he says.

In the case of C-sections, doctors may be motivated to perform the procedures because they allow for faster deliveries or better pay, Main says. But the main reason some doctors still perform too many episiotomies is probably that they always have done so — in some cases for decades.

"It is always hard for people to relearn," Main says.

His organization is leading an effort to provide doctors and hospitals with data on certain childbirth practices, to show them how they compare with their peers around the state. Beginning in 2010, the group partnered with the March of Dimes to educate providers about the dangers of elective delivery prior to 39 weeks. Within three years, that practice had dropped off rapidly, he says. The organization is currently undertaking similar efforts related to C-sections.

Chavira, the maternal and fetal medicine specialist at California Hospital in Los Angeles, says he would like to see similar transparency with data on episiotomies.

"If you have a hospital where people are doing 5 percent episiotomies and one guy is doing 60 percent episiotomies, all of a sudden he sticks out like a sore thumb," Chavira says.

A lot of women don't want the procedure, Chavira notes, and doctors are supposed to honor their patients' wishes.

In June, a Superior Court judge in Los Angeles County ruled that Turbin's lawsuit against her former obstetrician can go to trial in the fall. Meanwhile, Turbin says she is terrified of getting pregnant again.

"If I go back to that day, there's nothing I could have done," she says. "That doctor was going to cut me, no matter what."

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. (Kaiser Permanente has no relationship with Kaiser Health News.)

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Few Young Doctors Are Training To Care For U.S. Elderly

NPR Health Blog - Sun, 07/03/2016 - 5:02pm
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Mary Mullens, age 93, in her room at Edgewood Summit Retirement Community in Charleston, W.Va. Mullens is a patient of Dr. Todd Goldberg, one of only 36 geriatricians in the state.

Kara Lofton/West Virginia Public Broadcasting

At Edgewood Summit retirement community in Charleston, W.Va., 93-year-old Mary Mullens is waxing eloquent about her geriatrician, Dr. Todd Goldberg.

"He's sure got a lot to do," she says, "and does it so well."

West Virginia has the third oldest population in the nation, right behind Maine and Florida. But Goldberg is one of only 36 geriatricians in the state.

"With the growing elderly population across America and West Virginia, obviously we need healthcare providers," says Goldberg.

That includes geriatricians — physicians who specialize in the treatment of adults age 65 and older — as well as nurses, physical therapists, and psychologists who know how to care for this population.

"The current workforce is inadequately trained and inadequately prepared to deal with what's been called the silver tsunami — a tidal wave of elderly people — increasing in the population in West Virginia, across America, and across the world really," Goldberg says.

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The deficit of properly trained physicians is expected to get worse. By 2030, one in five Americans will be eligible for Medicare, the government health insurance for those 65 and older.

Goldberg also teaches at the Charleston division of West Virginia University, and runs one of the state's four geriatric fellowship programs for medical residents. Geriatric fellowships are required for any physician wanting to enter the field.

For the past three years, no physicians have entered the fellowship program at WVU-Charleston. In fact, no students have enrolled in any of the four geriatric fellowship programs in West Virginia in the past three years.

"This is not just our local program, or in West Virginia," says Goldberg. "This is a national problem."

The United States has 130 geriatric fellowship programs, with 383 positions. In 2016, only 192 of them were filled. With that kind of competition, Goldberg laments, why would a resident apply to a West Virginia School, when they could get into a program like Yale or Harvard?

Adding to the problem, the average medical student graduates with $183,000 in debt, and every year of added education pushes that debt higher.

Dr. Shirley Neitch, head of the geriatrics department at Marshall University Medical School in Huntington, W.Va., says students express interest in geriatrics almost every year. But, "they fear their debt," she says, "and they think that they need to get into something without the fellowship year where they can start getting paid for their work."

This trend troubles many people, including Todd Plumley, whose mother Gladys has dementia, and lives in West Virginia.

"It's kind of scary that [older patients] don't have the care that they really need to help them through these times, and help them prolong their life and give them a better life," Plumley says.

There are no geriatricians in the family's hometown of Hamlin, so Plumley drives his mother almost 45 minutes to another town, Huntington, to see one. He says seeing this specialist has helped stabilize his mother's symptoms.

"Right now, if we didn't have the knowledge and resource," he says, "I believe my mother would have progressed a lot further along, quicker."

Plumley is in his 50s. He worries that if he needs the care of a geriatrician as he gets older, driving even 45 minutes may not be an option.

This story is part of NPR's reporting partnership with West Virginia Public Broadcasting and Kaiser Health News.

Copyright 2016 West Virginia Public Broadcasting. To see more, visit West Virginia Public Broadcasting.
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Community-Based Care Can Reduce The Stigma Of Mental Illness

NPR Health Blog - Sat, 07/02/2016 - 7:00am

Mental illness has been part of human society throughout recorded history, but how we care for people with mental disorders has changed radically, and not always for the better.

In Colonial days, settlers lived in sparsely populated rural communities where sanctuary and community support enabled the tradition of family care brought from England. "Distracted persons" were acknowledged, but erratic behavior wasn't associated with disease.

Records indicate unusual tolerance of bizarre behavior. When 18th century Pastor Joseph Moody of York, Maine, unable to face crowds, delivered sermons with a handkerchief covering his face, his behavior was tolerated for three years before he was relieved of his duties.

As urban areas grew in size and number, a transient poor population with no access to family support led to almshouses, the first form of institutionalization, inspired by 18th century reforms in Europe.

A Philadelphia Quaker who had visited an English retreat brought the idea to this country and in 1817 founded the Friends Asylum, a self-sufficient farm that offered a stress-free environment known as "moral treatment." Other private asylums followed, but they soon became overcrowded. By the late 19th century, this was addressed with larger state hospitals, which soon became overcrowded as well.

People with mental disorders are more likely to be stigmatized owing to fear and misunderstanding when they aren't part of the community. And stigmatization can discourage those with a mental disorder from seeking or complying with treatment. It also can lead to people being institutionalized against their will, more to protect the public than to provide compassionate care for those with mental illness.

President John F. Kennedy signs the bill intended to shift mental health care from state institutions to the community on Oct. 31, 1963.

Bill Allen/AP

In the mid-1950s, new antipsychotic medications offered relief from some of the most disabling symptoms of schizophrenia and other major disorders, such as psychosis and hallucinations. And in 1963, President John F. Kennedy's Community Mental Health Act shifted funding from large state hospitals, which had been plagued by scandal, to small-scale community-based mental health centers. With deinstitutionalization, the inpatient population dropped from over half a million in 1955 to about 60,000 by the end of the century.

By 1977, federally funded centers were serving close to 2 million people a year in 60 community mental health facilities. But the law was never adequately funded, and a national standardized system of community care did not emerge. As a result, people began to associate mental illness with homelessness or acts of violence, though the vast majority of people with mental illness pose no threat.

That raises the question of whether it's possible to reduce stigma so that those with a mental disorder are not feared and shunned. Patrick Corrigan, director of the National Consortium on Stigma and Empowerment, has investigated three approaches to reducing stigma: protest, education and contact.

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In one study, subjects received information regarding mental illness in the context of the three approaches. Statements meant to induce a sense of moral outrage protest produced no stigma reduction. Both education and contact with someone known to have a mental illness did produce significant changes in attitude — less blame toward persons with mental illness and greater confidence in their chance of recovery — and encouraged future contact with those known to have mental illness. Previous contact mitigated lingering stereotypes more than education.

The author (second from right) with boarders from Geel during a fishing outing in 2007.

Courtesy of Jackie Goldstein

To get a sense of how it is possible for community members to have contact with those with mental illness without inciting stigma and fear, it helps to take a look at present-day communities where that happens. For centuries, in Geel, Belgium, community contact has been an everyday event for those with mental illness, with the state paying families to care for "boarders" in their homes. Modern-day Geel combines community care with medical care and psychotherapy, as well as hospitalization if needed. (For more modern-day Geel, see Invisibilia's story here.)

In the United States, variations in state funding affect the quality of public mental health care. But dozens of programs offer evidence that it is possible to build sustainable fostering communities.

Community members enjoy a picnic on Gould Farm in Monterey, Mass., in the 1920s. Work on the farm remains a key part of the therapeutic process.

Courtesy of Gould Farm

Gould Farm, a working farm established in Monterey, Mass., in 1913, was the first modern-day residential therapeutic community in the U.S. Here patients are referred to as guests, and all staff — and their families — live on the farm. Daily work, on the farm or at its bakery or cafe, is a key aspect of the therapy.

Today Gould Farm is one of more than 30 members, in 15 states, of the American Residential Treatment Association. These programs are not covered by Medicare or Medicaid, but some ARTA members help families secure financing; health insurance may cover part of the cost. For example, more than 50 percent of Gould Farm "guests" receive financial assistance. But, for the most part, people must assume the expense of a six- to 12-month stay, ranging from $400 to $900 per day.

In Chicago, the Thresholds organization offers services to people with mental illness in more than 100 locations in the city and surrounding counties. It was founded in 1959, by women from Chicago's National Council of Jewish Women who attended a mental health educational conference and learned that people who had spent years in mental hospitals were often left to fend for themselves upon release. It started as a small volunteer organization that offered social activities, then grew to include residential programs, supported employment, housing-first, and treatment for people with both mental diagnoses and substance disorders. Last year, 75 percent of its services were delivered in the community.

Thresholds is one of 15 programs I've visited across the United States in decades of researching models of community care in mental health. Those 15 are a small sample of programs of varying sizes that offer affordable housing or help in finding such housing; occupational training and placement; recreational opportunities and more.

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Those with a mental disorder can live a meaningful life, if their community facilitates community contact. It's been happening in Geel for centuries. It is happening in the U.S. today. The voice of stigma originates in the community, but so does the voice of hope.

Jackie Goldstein is a professor emeritus of psychology at Samford University and author of the 2016 book Voices of Hope for Mental Illness: Not Against, With.

This story is part of Invisibilia's episode on solutions, including a report on how residents of the town of Geel, Belgium, have been taking in strangers with mental illness as boarders for centuries. We also talked with Mr. Kitt, who found sobriety and his calling as an artist after he moved off the streets into a Broadway Housing Communities apartment in New York. And NPR reporters Pam Fessler and Nate Rott visit community housing sites on the East and West coasts that aim to provide sanctuary, not just shelter.

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